<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601319
Report Date: 04/24/2023
Date Signed: 04/24/2023 06:49:44 PM

Document Has Been Signed on 04/24/2023 06:49 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 RESIDENCEFACILITY NUMBER:
198601319
ADMINISTRATOR:JESSICA M. JARAMILLOFACILITY TYPE:
735
ADDRESS:638 N. CHAPMAN STREETTELEPHONE:
(626) 960-4248
CITY:WEST COVINASTATE: CAZIP CODE:
91790
CAPACITY: 4CENSUS: 4DATE:
04/24/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Marcos Hernandez TIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Christine Wong conducted the required annual inspection. LPA arrived unannounced and met with Administrator Marcos Hernandez who allowed the entry of the facility and assisted with the visit. Later on, the primary administrator Sandra Bote arrived. The purpose for the visit was explained. The facility is licensed to serve four developmentally disabled adults and two can be 'l
non-ambulatory.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and here are the domains that LPA inspected:

1, Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting the clients. Staff are cleaning and disinfecting each use for high touched surface area. Facility has sufficient PPE supplies and has an Infection Control Plan.
2. Physical Plant and Environmental: The facility is a single story house and located around the residential neighborhood area. The facility includes: a den/staff office, living room, dining area, kitchen, medication station, three (3) clients bedrooms, three bathrooms, laundry room, relaxation area and a detached garage. LPA inspected the smoke detectors and carbon monoxide detectors and they are located in each bedroom and common area and they are all working probably. LPA tested the hot water in the bathrooms and they were tested between 110.6 and 110.8 degrees F which is within the Title 22 regulation. All the sharp knives and utensils are locked in the kitchen drawer. All the chemicals and cleaning supplies are locked in the cabinet in the laundry room and cabinet in the kitchen. All the clients room are furnished and have required beddings.
3. Operational Requirements: The facility maintained a fire clearance approved by the fire department which two maybe non-ambulatory, currently the facility has two wheelchair clients. The facility also has shaded area with table and chairs for client to utilize for outdoor activity. The last fire drill was conducted on 4/1/23 and earthquake/disaster drill was conducted on 1/14/23.
(See LIC 809C for continuation)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 04/24/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
4. Staffing: The Night supervision staff does have the required training for the planned emergency procedure and there's sufficient staffing in the facility.
5. Personnel Record-Training: All the staff files are maintained in the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. The administrator's ( Sandra Bote) certificate expires on 3/10/23 but the administrator certificate application is pending now. The administrator also has an updated HIV and TB Training. Al the direct care staff has the updated first aid training and Medication Management Training.
6. Clients Right-Information: The facility does not have any client required postural support. The facility does serve adults has internet service shall provide at least one access device.
7. Client Records-Incident Reports: All the client files are maintained in the facility. All the files have the required documents included: admission agreement, updated physician report , Individual Personal Plan (IPP) and functional capacity assessment..etc.
8. Food Service: The facility has two days perishable and seven days non-perishable food supply. The refrigerator is maintained in the required temperature. All the food are stored probably.
9. Health Related Services: All client medication are centrally stored in the mediation station next to the kitchen. All the client's medication are reviewed and they are all seemed accurate and updated.
10. Incidental Medical Services: The facility does not have any client who has the restricted health condition or prohibited health condition.
11. Disaster Preparedness: The facility has an updated emergency disaster plan (LIC610D) posed with contact numbers and at least two relocation sites
12. Emergency Intervention: All staff have required training and its up-to-dated.

No deficiencies were observed during the annual inspection.

Exit Interview was conducted and a copy of the report was provided to Administrator Sandra Bote.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2