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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000801
Report Date: 08/24/2023
Date Signed: 09/20/2023 08:51:09 AM

Document Has Been Signed on 09/20/2023 08:51 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:CHAPMAN BOARD & CAREFACILITY NUMBER:
306000801
ADMINISTRATOR:BRYSON NAZARENOFACILITY TYPE:
735
ADDRESS:10811 CHAPMAN AVE.TELEPHONE:
(714) 638-8777
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 49CENSUS: 49DATE:
08/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Helen Balbalang
Matthew Nazareno		TIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA met with Facility Manager (FM) Helen Balbalang and discussed the purpose of the inspection. Administrator (AD) Matthew Nazareno was contacted by phone and arrived at 9:30 a.m.

During the inspection LPA and FM conducted a tour of the inside and outside of the facility, common areas, client rooms, staff offices, kitchen, dining room, and observed the following:

This is a one-story complex with 24 client bedrooms, and three common bathrooms, most client bedrooms contain half bathrooms as well. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. LPA observed all windows were screened. The courtyard has a shaded sitting area. LPA observed maintenance staff and direct care staff and clients throughout the facility. Clients were observed resting in their respective bedrooms, watching television, and conversing in the courtyard. Bathrooms were observed to be free of debris, faucets and toilets were operational. Water temperature tested at 144.1 F degrees; a Deficiency was cited on today’s date.

LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted in the facility staff office. LPA observed the facility exceeds 2-day supply of perishables and a 7-day supply of non-perishable food required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguishers were observed to be mounted and fully charged. Stove burners, microwave, washer, and dryer were all inspected. Sharps were observed locked in the kitchen. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication cabinet was observed to be locked in the staff office. LPA reviewed seven client files and five staff files. LPA interviewed seven clients and three staff. (Cont. LIC809-C)
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2023
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: CHAPMAN BOARD & CARE
FACILITY NUMBER: 306000801
VISIT DATE: 08/24/2023
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Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/20/2023 08:51 AM - It Cannot Be Edited


Created By: Claudia Gutierrez On 08/24/2023 at 02:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CHAPMAN BOARD & CARE
FACILITY NUMBER: 306000801

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as cobwebs were observed hanging from the ceiling throughout the dining area and a cabinet door is missing in one client bathrooms which poses a potential health and safety risk to persons in care.
POC Due Date: 09/22/2023
Plan of Correction
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AD stated they would do a sweep of the ceiling in dining room area and provide kitchen staff training to ensure celling remains cobweb free. AD stated they would provide LPA email proof of staff training sign-in sheet and picture proof of dining room ceiling cobweb free.
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on testing conducted, the licensee did not comply with the section cited above as hot water delievered to plumbing fixtures tested at 144.1 which poses a potential safety risk to persons in care.
POC Due Date: 09/22/2023
Plan of Correction
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AD stated they would keep a water temperature log and check the water temperature daily. AD will provide LPA with a copy of water temperature log used to record daily temperatures via email by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023


LIC809 (FAS) - (06/04)
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