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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197802685
Report Date: 11/22/2022
Date Signed: 11/22/2022 04:33:59 PM


Document Has Been Signed on 11/22/2022 04:33 PM - 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:MONTEREY PARK HOMEFACILITY NUMBER:
197802685
ADMINISTRATOR:JENNIFER PICHINTEFACILITY TYPE:
735
ADDRESS:1539 FELIZ STTELEPHONE:
(626) 289-8701
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91754
CAPACITY:6CENSUS: 6DATE:
11/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Marietta Belleza, House ManagerTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit to address the allegations that were self reported by the facility. LPA met with House Manager, Marietta Belleza, and explained the purpose of the visit.

LPA obtained an incident report indicating that Client #1 (C-1) was hit and yelled at by Staff #1 and #2 (S-1, S-2). C-1 could not recall the date of the incidents nor give specific details. Client #1 was interviewed today and stated that the staff never hit the clients. However, C-1 stated that only Staff #1 yelled in Client's ears which client did not like. C-1 stated that the staff do not use bad words or say mean things to clients. LPA interviewed a staff who stated that C-1 fabricate stories and repeats what others say at times. Interview with the previous Administrator stated that C-1 stories are inconsistent and can change throughout the day. Staff has not observed any other staff physically or verbally abusing clients. Staff also stated that the 2 staff have recently resigned from working at the home.

LPA obtained copies of Client #1's Individual Program Plan and Behavioral Plan.

No deficiencies were issued during the visit today. An exit interview was held and a copy of this report was given to the House Manager.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022
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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