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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000801
Report Date: 11/08/2022
Date Signed: 11/08/2022 02:42:31 PM

Document Has Been Signed on 11/08/2022 02:42 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: 49DATE:
11/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Matthew NazarenoTIME COMPLETED:
02:30 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 incident report received in the Orange County Regional Office (OCRO) on 11/04/22 regarding Resident #1 (R1). LPA met with Administrator (AD) Matthew Nazareno and discussed the purpose of the inspection.

The incident report states that on 10/27/22, facility staff noticed R1 was not present at the facility when facility staff went to pass out medications and the facility reported R1 was missing to the Garden Grove Police Department (GGPD), R1’s responsible party, and R1’s doctor.

During today’s inspection, LPA interviewed AD and reviewed GGPD paperwork and R1’s resident file. AD stated that on 10/27/22, R1 was seen by 2 residents early in the day, but could not be found when facility staff went to pass medications. AD filed a missing person report with GGPD on 10/27/22. R1 does not have a history of elopement and only rarely leaves the facility. As of today’s inspection, R1 has not returned to the facility. AD stated that AD followed up with GGPD multiple times since 10/27/22 and was eventually referred on 11/07/22 to the Orange County Sheriff’s Department (OCSD). AD followed up with the OCSD on 11/07/22 and was told that the OCSD had found R1 nearby, but had let R1 go and closed their missing person file. On 11/08/22, AD followed up with GGPD and was advised to refile the missing person’s report. AD is planning to refile the missing person’s report in person today at the police station. LPA reviewed R1’s Physician’s Reports for Residential Care Facilities for the Elderly (RCFE) LIC602A dated 03/29/21 and 02/24/20 both of which state that R1 is able to leave the facility unassisted. AD stated the facility has a sign-out sheet and encourages residents to sign out when they are leaving, that most residents comply with the sign-out sheet, but that R1 did not sign out on this occasion. AD stated that R1 has no history of elopement and rarely leaves the facility. AD stated that the facility does not know why R1 left, that there were no events or incidents leading up to R1 leaving, R1 did not have a change of condition, and that R1 was scheduled to receive a physical from R1’s physician this week.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2022
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: 11/08/2022
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AD stated that facility staff go around every hour to check on residents, all residents receive medications from the medication room daily, and if a resident does not come for their medications staff will go to the resident’s room to check on them and that is how the facility discovered R1 was not present. AD stated that the facility has an elopement protocol and which the facility followed during this incident.

Based on the observations made during today’s inspection, no 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 was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
LIC809 (FAS) - (06/04)
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