198601319-2-6-2023-28-AS-KRAZ-CNSU5B-20230206141630

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601319
Report Date: 11/15/2022
Date Signed: 02/06/2023 02:17:08 PM

Document Has Been Signed on 02/06/2023 02:17 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:	CHAPMAN RESIDENCE		FACILITY NUMBER:	198601319
ADMINISTRATOR:	JESSICA M. JARAMILLO		FACILITY TYPE:	735
ADDRESS:	638 N. CHAPMAN STREET		TELEPHONE:	(626) 960-4248
CITY:	WEST COVINA	STATE: CA	ZIP CODE:	91790
CAPACITY: 4		CENSUS: 4	DATE:	11/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator Sandra Bote		TIME COMPLETED:	12:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Administrator Sandra Bote and explained the reason for the visit. Physical Plant was toured, sample record of medications were reviewed, and food supply was inspected.

LPA and Administrator toured the home and inspected (3) client bedrooms, (3) bathrooms, kitchen, den, dining room, living room, side patio, and detached garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the clients located in the side patio. Passageways and exits are free of obstruction. The facility is licensed for clients 18-59 years old. However, there are 4 clients over the age of 60, which exceeds 50% of census. The licensee must request an exception in order to accept or retain the individual. Licensee Jessica Montesinos, indicated she has correspondence from another LPA indicating an Age Exception Waiver is/was no longer required. If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50% of the census in facilities with a capacity of six or fewer clients, or 25% of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The documentation specified in Section 85068.4(c) must be submitted with the exception request. LPA Ramirez will grant the licensee 4 business days (11-18-22) from 11-15-22 to provide proof of correspondence. Administrator certificate expires on 03-10-2023.

*CONT 809C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
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.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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: CHAPMAN RESIDENCE	FACILITY NUMBER: 198601319
	VISIT DATE: 11/15/2022

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OBSERVATIONS:
· The water temperature was tested in bathroom #1 and measured at 111.0F which is within the required 105 - 120 degrees. Client bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Client beds have the required linen and the linen is in remarkable condition. Smoke detectors were observed throughout the facility and were tested and operable during the visit. Carbon monoxide detector in the hallway of the home was tested and operable. There is a fire extinguisher located in the kitchen which is fully charged. Sharp objects were observed to be locked in a kitchen cabinet and are inaccessible to clients. Cleaning supplies and toxins are locked in a cabinet located in the kitchen area. First Aid kit was fully stocked with current manual.

·Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing.
· Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed.
· (4) out of the (4) client medications were reviewed. Medications are centrally stored in a cabinet located by the kitchen. Medications are documented properly and given as prescribed.
· Staff files were reviewed during today's visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview held and a copy of the report was provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
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

LIC809 (FAS) - (06/04)

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