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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601319
Report Date: 03/11/2024
Date Signed: 03/11/2024 02:51:38 PM

Document Has Been Signed on 03/11/2024 02:51 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
CCLD Regional Office, 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: 3DATE:
03/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Marcos HernandezTIME COMPLETED:
03:00 PM
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Licensing Program Analysts (LPA) Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPA met with Administrator Marcos Hernandez who assisted with the visit. LPA explained the reason for the visit.

The physical plant was inspected along with COVID-19 procedures, medications, food supply, and resident and staff records. The facility is licensed to serve developmentally disable clients between the ages 18 to 59 and vendorized by San Gabriel/Pomona Regional Center. There are currently 3 clients residing at the home and receive services from San Gabriel / Pomona regional Center. All 3 clients were at the Day program at the time of visit.

LPA toured the home and inspected three (3) client bedrooms, three (3) bathrooms, kitchen, dining room, the den, living room, and detached garage. The front and backyard are well maintained and there are no pools or large bodies of water. Passageways and exits are free of obstruction. There is a shaded seating area for the clients located in the backyard. Laundry was observed in the exit hallway. LPA observed laundry detergent locked in the cabinet and not accessible to clients. There is only one entrance being utilized at the facility. There is a fireplace located in the den which is covered by a screen.


Client bedrooms were checked. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. The client bathrooms were toured. Bathrooms have the required hygiene items, grab bars and non-skid mat. The hot water temperature was tested and was measured within Title 22 Regulation guidelines. Extra linens, blankets, towels, and personal hygiene supplies were observed. The kitchen was inspected. There is sufficient perishable and non-perishable food. More non- perishable food was observed in the garage. All the appliances are clean and working properly. Sharps are locked in a kitchen cabinet inaccessible to clients.

Continue 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2024
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: CHAPMAN RESIDENCE
FACILITY NUMBER: 198601319
VISIT DATE: 03/11/2024
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Fire extinguisher observed in the kitchen fully charged. Carbon monoxide/smoke detector in the dining room and in the client rooms are operational. The First Aid kit was fully stocked with all required items including a current manual. Centrally stored medications are stored in a locked cabinet in the kitchen / medication area. LPA reviewed clients and staff files. LPA confirmed staff working have fingerprint clearances. LPA reviewed client’s medications. Medications are documented properly and given as prescribed. Last Fire drill was conducted on 03/03/2024.

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 to Marcos Hernandez.


SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024
LIC809 (FAS) - (06/04)
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