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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000801
Report Date: 10/26/2022
Date Signed: 10/26/2022 10:51:11 AM

Document Has Been Signed on 10/26/2022 10:51 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: 48DATE:
10/26/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Matthew NazarenoTIME COMPLETED:
11:00 AM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of issuing citations for deficiencies observed during the investigation into Complaint Control No. 22-AS-20220720140534. LPA met with Administrator (AD) Matthew Nazareno and explained the reason for today’s inspection. The investigation into the allegation that Facility is in disrepair revealed the following: During the course of the investigation, LPA inspected the facility, interviewed AD, 1 witness, 1 resident, and 2 staff, and requested and reviewed copies of the resident roster, staff roster, and an Edison Environmental Protection letter dated 08/10/22.

On 10/04/22, LPA observed a large hole that had been created in the ceiling of Room 20 that appeared to be part of some construction work. LPA also observed that the 2 resident beds in this room had been moved to the front common room. AD stated in interviews that the 2 residents who reside in Room 20 slept in the front common room on the night of 10/04/22 because construction to repair the ceiling was taking place, the company completing the construction advised against allowing residents to sleep in the room during construction, and the facility does not have any vacant rooms to house the residents during construction. AD stated that repairs were completed on 10/05/22 and the 2 residents slept back in Room 20 on the night of 10/05/22. On 10/12/22 and during today's inspection, LPA observed and confirmed that the ceiling in Room 20 has been completely repaired and the beds are back in the room. On 10/26/22 LPA interviewed the residents who reside in Room 20 and confirmed that they slept in the living room for 1 night and then returned to their room. AD stated that in future cases of construction AD will stop accepting new residents to ensure the room can remain unoccupied during construction.

Based on the interviews conducted and observations made during the investigation, violations are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2022
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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Document Has Been Signed on 10/26/2022 10:51 AM - It Cannot Be Edited


Created By: Sean Haddad On 10/26/2022 at 10:22 AM
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: 10/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/27/2022
Section Cited
CCR
85087(a)(3)

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85087 Buildings and Grounds (a) …: (3) No room commonly used for other purposes shall be used as a bedroom for any person. This requirement was not met as evidenced by:
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Proposed POC: On 10/12/22 and during today’s inspection, LPA confirmed that the residents in Room 20 are back in their room and that they spent 1 night in the living room.

POC CLEARED
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Based on observations and interviews, the facility required 2 residents to sleep in the front common room for 1 night while their room was being repaired, which poses an immediate personal rights risk to residents in care.
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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:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022


LIC809 (FAS) - (06/04)
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