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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000801
Report Date: 08/02/2023
Date Signed: 08/02/2023 02:21:02 PM

Document Has Been Signed on 08/02/2023 02:21 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: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: 47DATE:
08/02/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:31 PM
MET WITH:Matthew NazarenoTIME COMPLETED:
02:34 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced case management visit in conjunction with complaint # 22-AS-20230725161140. LPA met with Administrator Matthew Nazareno and explained the reason for the visit. During the complaint investigation LPA Alejandre observed the following that is not related to the complaint. LPA toured the facility with staff. LPA did not observe any odors in the facility or Client 1's room or bathroom. LPA observed the toilet in C1's bathroom was slightly tilted. LPA observed there was a stain on the ceiling of C1's room. LPA observed the tile floor is missing numerous tiles by the door to C1's room. LPA observed the sink wall above the sink in C1's room is not clean. Based on the observations made during today's visit 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 discussed with and provided to facility representative.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2023
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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Document Has Been Signed on 08/02/2023 02:21 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 08/02/2023 at 01:51 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: 08/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/11/2023
Section Cited
CCR
80087(a)

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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 being met as evidenced by, LPA observed C1's toilet was slightly tilted, LPA observed
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Licensee agrees to fix the toilet in C1's room, to clean the sink and wall in C1's room and to replace the missing tiles in C1's room. Licensee to forward proof to LPA by POC due date.
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the tile floor is missing numerous tiles by the door to C1's room. LPA observed the sink wall above the sink in C1's room is not clean.
This poses a potential health and safety risk to staff and clients 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:Luz Adams
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023


LIC809 (FAS) - (06/04)
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