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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600523
Report Date: 11/15/2022
Date Signed: 11/15/2022 12:11:59 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/06/2021 and conducted by Evaluator Troy Agard
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210806090415
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:
11/15/2022
UNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Bessie Coello TIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Resident sustained unexplained injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Troy Agard conducted an unannounced subsequent complaint visit at the above facility. LPA met with Administrator, Bessie Coello and explained the purpose of the visit.

On 11/15/2022 LPA toured the facility, conducted interviews and requested records. The facility is located in a residential area. The facility is part of a one-story duplex which is located on the back. Front duplex is not licensed by Community Care Licensing. The single-story facility includes: three (3) client bedrooms; living room, kitchen with laundry area, dining area, two (2) bathrooms, and an attached two car garage with an outside shaded area. LPA requested a staff and client roster, C1’s behavior intervention plan for August 2021, behavior data and any incident reports during the August 2021 time frame.

Cont. on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Troy Agard
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
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-20210806090415
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: COELLO'S RESIDENTIAL CARE
FACILITY NUMBER: 198600523
VISIT DATE: 11/15/2022
NARRATIVE
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After interviews and record review the investigation revealed that there is no preponderance of evidence to support the following allegation: Resident sustained unexplained injury. LPA interviewed 2 out of 7 staff in total. 2 out of 2 denied the allegation. S1 states, the client has a history of self-injurious behavior. No one ever hit C1. The person that’s being alleged doesn’t even work at the facility. S2 states, “no one hit C1. C1 will throw themself down and hit themself all the time. We stop it as much as we can.” LPA was unable to interview any clients due to their cognitive functions. Which includes C1.

During a record review, LPA reviewed C1’s behavior intervention plan for August 11, 2021. Report states that client has a history of self-injurious behavior. Client is currently working on outcomes to help in decreasing their maladaptive behaviors. Client has been on the same outcomes as early as 2016. LPA reviewed a behavior data sheet for the month of October 2022 that shows the facility is working with the client on decreasing them being physically aggressive towards self. LPA reviewed an incident report dated for August 12, 2021 that was sent to Community Care Licensing which speaks to client being hospitalized for a possible seizure around the same timeframe. LPA observed client to be clean, healthy, safe, happy and free of injury.

Based on LPA’s observation, interviews conducted, and record review, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted, and a copy of this report was given.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Troy Agard
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2