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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000801
Report Date: 07/19/2022
Date Signed: 07/19/2022 11:56:01 AM

Document Has Been Signed on 07/19/2022 11:56 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:
07/19/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Matthew NazarenoTIME COMPLETED:
12:10 PM
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This unannounced case management inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported death report received in the Orange County Regional Office (OCRO) on 07/18/22 regarding Resident #1 (R1). LPA met with Administrator (AD) Matthew Nazareno and discussed the purpose of the inspection.

The death report states that on 07/09/22, R1 passed away at Garden Grove Hospital due to a cardiac arrest. A related incident report received in the OCRO on 07/18/22 provides the following information: R1 was 43 years old; on 07/09/22, another client reported to staff that R1 had collapsed in the bathroom; staff called 911; paramedics arrived, applied CPR to R1, and transported R1 to Garden Grove Hospital; staff notified R1’s family and doctor; and on that same day Garden Grove Hospital called and advised the facility that R1 had passed away. Per AD, the facility originally faxed these reports to the OCRO on 7/11/22, but the fax did not go through so the reports were re-faxed. AD also reported the incident to LPA by phone prior to 07/18/22 and LPA had advised AD to gather all of the information and submit a completed death report.

During today’s inspection, LPA toured the facility with AD, interviewed AD and staff, conducted health and safety checks on residents, and requested and reviewed the staff roster, resident roster, R1’s resident file, and other pertinent records.

Interviews with AD and Staff #1 (S1) confirmed the information provided in the reports received 07/18/22. AD and S1 also provided the following information: R1 had a diagnosis of schizophrenia; R1 had received doctor’s orders to limit sugar; AD, S1, and facility staff regularly encouraged R1 to follow doctor’s orders and to eat healthy, but R1 regularly drank soda and received sweet treats from visiting family; R1 had no major health issues in the last 6 months and did not complain of any symptoms, but had gained weight;
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2022
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: CHAPMAN BOARD & CARE
FACILITY NUMBER: 306000801
VISIT DATE: 07/19/2022
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 R1’s doctor comes monthly to the facility to visit R1 and other residents, but R1 refused to see their doctor approximately 50% of the time; there was no indication that R1 would pass away so suddenly and AD, S1, and R1’s family were shocked; the paramedics arrived within 5 minutes of facility staff calling 911; paramedics applied CPR to R1 along with defibrillator and oxygen mask; while waiting for 911 to arrive, facility staff followed all instructions provided by 911; Garden Grove Hospital called the facility just 30 minutes after R1 arrived to notify the facility that R1 had passed away. LPA conducted health and safety checks on 11 residents and confirmed they were doing well and observed no health and safety issues.

During the inspection, LPA removed R1’s resident file from the facility and advised AD that LPA will return the file within 3 days.

Facility representative was advised that at this time further investigation may be required. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022
LIC809 (FAS) - (06/04)
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