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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602865
Report Date: 10/15/2024
Date Signed: 10/15/2024 10:52:00 AM

Document Has Been Signed on 10/15/2024 10:52 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:CHELLE'S HOMEFACILITY NUMBER:
197602865
ADMINISTRATOR/
DIRECTOR:		PINEDA, ROMEO P.FACILITY TYPE:
735
ADDRESS:3234 ALAMEDA STREETTELEPHONE:
(626) 568-0324
CITY:PASADENASTATE: CAZIP CODE:
91107
CAPACITY: 4CENSUS: 2DATE:
10/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Millet Pineda - Administrator TIME VISIT/
INSPECTION COMPLETED:
11:05 AM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted a case management visit during a complaint investigation visit. LPA met with Millet Pineda and explained the reason for the visit.

On 10/15/24 LPA Flores conduted a complaint investigation for complaint # 28-AS-20241009095559. During this investigation the following was reviewed: Incident report dated: 10/9/24, which reports and incident between clients living at the facility that occurred on 10/8/24. It was revealed that two clients were hurt by another client on 10/8/24. Staff #2(S2) was the staff in care of clients at the time and was in the kitchen when Client #2(C2) hit Client #1(C1) in the face, C1 began to cry and S2 told C1 “Stop crying and go to your room” at least three times. This was a statement given to LPA on the date the incident occurred during another complaint investigation. Upon paramedics arriving at the facility C2 was observed in the front yard in an emotional outburst. However, there was no staff assisting C2. C3 was taken to the hospital after obtained a head injury that required 4 staples due to the incident between the clients. Documents reviewed revealed C2 had been showing aggressive behaviors in the month of September. Although it was determined S2 has all the required training to provide care. S2 did not use proper descaling techniques to assist any of the clients at the time of the incident. Staff spoke to C2 without emotional awareness resulting in a violation of clients’ personal rights.

Therefore a deficiency is noted on LIC 809D.

Exit interview was conducted and a copy of this report LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/15/2024 10:52 AM - It Cannot Be Edited


Created By: Mary G Flores On 10/15/2024 at 10:36 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: CHELLE'S HOME
FACILITY NUMBER: 197602865

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/16/2024
Section Cited
CCR
80065(a)(2)

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80065 Personal Rights: (a)... each client shall have personal rights ...: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement is not met as evidence by:
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Administrator will provide training additional training on proper descaling techniques and communication with the clients in care by POC due date and submit a copy of training to all staff to the department by POC due date 10/16/24.
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Licensee did not ensure that S2 utilize proper descaling techniques with clients in care which poses an immediate risk to the health, safety, and personal rights of the persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


LIC809 (FAS) - (06/04)
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