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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300613047
Report Date: 06/06/2023
Date Signed: 06/07/2023 07:58:43 AM

Document Has Been Signed on 06/07/2023 07:58 AM - 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: 6DATE:
06/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Elizabeth HalahanTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility to conduct a Required - 1 Year evaluation. LPA was greeted and granted entry by Carestaff Edith Carels and Ron Mahler and reason for visit was explained. Licensee/Administrator Elizabeth Halahan arrived shortly after. LPA noted Administrator has a certificate, which expired on 01/21/2023. LPA verified AD completed renewal training and is awaiting certificate.
The facility currently has 6 clients; 5 present during today's visit. One is on vacation with family. LPA Martinez, along Licensee Halahan conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following: Facility is a one story house with 7 bedrooms, 3 bathrooms, living room, kitchen, dining room, staff quarters, and an attached two car garage that is used for storage. LPA observed the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. A huge pool takes up the entire back yard. LPA observed the pool was gated and locked.
Client bedrooms were observed to be spacious and easily accommodate furnishings such as lamps, chair, dresser and a bed. Facility does have live-in staff. Bathrooms were clean, faucets, showers and toilets were operational. Hot water temperature in client bathroom was within regulatory requirements. Linen and hygiene supplies were stocked in hallway closet. Hygiene supplies are provided for number of client's in care. Emergency Phone Numbers and Exit Plan were reviewed. Food prep area is and organized. Food supply was noted to be in sufficient quantities to meet the regulatory requirements of a 2-day perishables and 7-day non-perishables. Emergency food and water supply is available. Smoke detectors and carbon monoxide detectors were found to be operational. Fire Extinguisher were charged and mounted, last charged on 07/26/2022. Fire drills are conducted once a month and LPA verified last Fire Drill was conducted on 05/07/2023. Stove burners, microwave, dishwasher, washer, and dryer are operational. Chemicals and sharps are made inaccessible to the clients. Medications are centrally stored in a locked medication cabinet in the kitchen. Medications reviewed appear to have been dispensed accurately.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2023
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: 06/06/2023
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First-Aid Kit had all the required elements and Activity Supplies were observed and available. There is a working land line at the facility. The LIC610D, Emergency Disaster Plan is posted.

LPA reviewed six client files and two staff file. Clients P&I records were unavailable.

Based on observations made, no deficiencies were observed at this time in the areas evaluated. An exit interview was conducted with AD and a copy of this report will be sent to email on file.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023
LIC809 (FAS) - (06/04)
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