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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600523
Report Date: 06/17/2022
Date Signed: 06/17/2022 11:58:38 AM

Document Has Been Signed on 06/17/2022 11:58 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:COELLO'S RESIDENTIAL CAREFACILITY NUMBER:
198600523
ADMINISTRATOR:COELLO, BESSIE L.FACILITY TYPE:
735
ADDRESS:4325 WEST 168TH STREETTELEPHONE:
(310) 292-8425
CITY:LAWNDALESTATE: CAZIP CODE:
90260
CAPACITY: 6CENSUS: 4DATE:
06/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:11 AM
MET WITH:Bessie CoelloTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Jey Cardenas conducted a case management visit to the above facility due to during a complaint investigation control number 11-AS-20211215111839 LPA observed deficiency not related to the complaint allegation. LPA met with Staff#3 and Conducted a Covid-19 risk assessment.

During complaint investigation LPA Cardenas observed C1 wearing a protective device; helmet for safety purposes. Per IPP Dated: 10/07/2020 C1 is diagnosed with profound intellectual disability, psychosis, and Impulse control disorder. Goals include reducing instances of injuring self, being physically aggressive, removing clothes, spitting, smearing saliva, and emotional outbursts. Emotional outbursts include screaming, yelling, jumping, falling on the ground and or/ tearing paper or breaking items. C1 exhibits self injurious behaviors like slapping/ hitting self, picking at face, fingers, chest, and stomach, as well as scratching or biting lips.

Bessie Coello indicates that numerous meetings have been taking place with C1's support team and are in agreement for the use of helmet.

On today 6/17/22 LPA Cardenas is issuing a deficiency due to LPA has not obtained written requests to use protective devices on C1.


Exit interview conducted, a copy of this report provided to staff, deficiency entered on LIC809D report and appeal rights provided.
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2022
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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Document Has Been Signed on 06/17/2022 11:58 AM - It Cannot Be Edited


Created By: Jey Cardenas On 06/17/2022 at 11:24 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 DR #100
MONTERY PARK, CA 91754

FACILITY NAME: COELLO'S RESIDENTIAL CARE
FACILITY NUMBER: 198600523

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2022
Section Cited
CCR
80072(a)(8)(F)(1)

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Personal Rights- All requests to use protective devices shall be in writing and include a written order of a physician indicating the need for such devices. The licensing agency shall be authorized to require additional documentation
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Administrator shall submit written request for use of protective device (helmet) and the reason for helmet, doctors orders for helment, and authorized representative conset for use of helment, and most recent IPP.
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including, but not limited to, the Individual Program Plan (IPP) as specified in Welfare and Institutions Code Section 4646, and the written consent of the authorized representative, in order to evaluate the request.
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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:Angela J Kendrick
LICENSING EVALUATOR NAME:Jey Cardenas
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2022


LIC809 (FAS) - (06/04)
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