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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300613047
Report Date: 05/17/2022
Date Signed: 05/17/2022 01:48:25 PM

Document Has Been Signed on 05/17/2022 01:48 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:H & C CHAPMANFACILITY NUMBER:
300613047
ADMINISTRATOR:HALAHAN, ELIZABETHFACILITY TYPE:
735
ADDRESS:2652 E. CHAPMANTELEPHONE:
(714) 525-6331
CITY:FULLERTONSTATE: CAZIP CODE:
92831
CAPACITY: 6CENSUS: 5DATE:
05/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Elizabeth HalahanTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit to conduct the annual (mitigation) inspection in this facility. LPA arrived at 12:05 pm and rang the doorbell three times and left two voice messages for Administrator (Admin) Elizabeth Halahan. On the third attempt, LPA spoke to the Admin on the phone and stated the purpose of the visit. The Admin or caregivers were not present at the facility. Admin stated Admin would arrive to assist with the annual inspection. Admin arrived at 12:50 pm, and LPA toured the facility after completing the Coronavirus 2019 (COVID-19) screening procedure.

This facility is a single level structure and licensed for 6 ambulatory clients. The facility offers a Level 3 service. As of today, LPA observed no clients and caregivers present as the clients were at their respective jobs, day program, and volunteering participating in recycling supervised by the house staff. At 1:00 pm, LPA toured the interior and exterior portions of the facility. LPA observed the required department postings at the front door and all around the facility as well as hand washing signs in the restrooms. LPA observed all restrooms had ample soap/sanitizer, paper towels, and appeared clean. Bathrooms were provided with grab bars and a non-skid floor mat. Clients' bedrooms appeared clean and sanitary and had all required components. Smoke detectors, carbon monoxide, and auditory exit alarms were tested operational. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Sharp items, medications, and cleaning supplies were inaccessible to the clients in care. For the exterior portion, facility had patio furniture under ample shading. LPA observed the pool was gated and locked. LPA observed the emergency disaster and evacuation plans. Facility does have back-up emergency food and water supply and has a 30 day supply of PPEs. The First Aid Kit met all the required elements. LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. LPA observed a laptop was provided for client use in the dining room.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2022
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: H & C CHAPMAN
FACILITY NUMBER: 300613047
VISIT DATE: 05/17/2022
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LPA reviewed the approved COVID-19 mitigation plan of the facility. No deficiency cited in this review as per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator Elizabeth Halahan, and a copy of this report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC809 (FAS) - (06/04)
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