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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602542
Report Date: 10/18/2024
Date Signed: 10/18/2024 04:20:49 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/13/2024 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20240913111323
FACILITY NAME:CHELSEA RESIDENTIAL CAREFACILITY NUMBER:
198602542
ADMINISTRATOR:HARRISON, HONORAFACILITY TYPE:
735
ADDRESS:2030 W 144 STREETTELEPHONE:
(310) 515-4757
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY:4CENSUS: DATE:
10/18/2024
UNANNOUNCEDTIME BEGAN:
04:11 PM
MET WITH:Joan Forbes, Direct Support ProviderTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Staff illegally evicted a resident in care.
INVESTIGATION FINDINGS:
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On 10/18/24, Licensing Program Analyst, (LPA) Felisa Shirley conducted an unannounced subsequent visit to this facility. LPA was met by staff, Joan Forbes and explained the purpose of the visit is to deliver findings for the allegations mentioned above. LPA was granted access to the facility.

The investigation consisted of the following:
On 9/16/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by Zoie Clark, Administrator. LPA requested LPA Shirley received copies of the following: LIC 500, Resident Roster, Resident Face Sheet, and IPP. LPA interviewed S1 and S2. On 9/26/24 LPA Shirley interviewed S3 and C2 and C3.



The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 11-AS-20240913111323
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: CHELSEA RESIDENTIAL CARE
FACILITY NUMBER: 198602542
VISIT DATE: 10/18/2024
NARRATIVE
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Allegation: Staff illegally evicted a resident in care

On 9/16/24, LPA Felisa Shirley interviewed facility Administrator, Zoie Clark. Per administrator, C-1 was a respite emergency placement from Westside Regional Center. Per interview with Administrator, C-1 demonstrated violent behaviors and caused destruction to the facility since day of admission of 8/31/24. Resident was taken to Harbor UCLA Medical Center to be placed on a 51/50 hold for breaking items at the facility and biting a staff’s arm. LPA spoke with Westside Regional Center, Placement Coordinator, W-1 regarding clients’s retrieval from UCLA Medical Center and she confirmed that C-1 could not return to Chelsea Residential Care as C-1 needed a 3 to 1 placement and Chelsea Residential Care could not accommodate this client.



LPA Shirley interviewed staff-1 thru staff-3 (S-1 thru S-3). LPA asked, did staff if they illegally evicted a resident in care? Of those interviewed, 3 out of 3 answered no. LPA interviewed Client-2 and Client-3 (C-2 and C-3). C-1 was not available, and C-3 did not answer the question. LPA asked clients if they had been illegally evicted from this facility?” Of those interviewed, 1 out of 1 answered no. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff illegally evicted a resident in care,” therefore the allegation is unsubstantiated.

There were no deficiencies cited during this visit.

LPA conducted an exit interview and a copy of this report was signed by staff Joan Forbes, and a copy left for Administrator, Zoie Clark.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2