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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000801
Report Date: 02/13/2023
Date Signed: 02/13/2023 09:26:17 AM

Document Has Been Signed on 02/13/2023 09:26 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: 47DATE:
02/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Matthew NazarenoTIME COMPLETED:
09:35 AM
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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 02/10/23 regarding Resident #1 (R1). LPA met with Administrator (AD) Matthew Nazareno and discussed the purpose of the inspection.

The incident report states that on 02/08/23, R1 withdrew all of their personal and incidental funds, took their morning medications, and went to their room, but that later during room checks facility staff noticed R1 was not present at the facility. Facility staff reported R1 missing to the Garden Grove Police Department (GGPD), R1’s responsible party, and R1’s doctor.

During today’s inspection, LPA reviewed R1’s resident file and interviewed AD. LPA reviewed R1’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) LIC602A dated 02/01/23 which states that R1 is able to leave the facility unassisted and that R1 does not have any memory care diagnoses. AD stated that this is the second time R1 has left the facility and that R1 previously left on 10/27/22, was the subject of a missing persons report, was missing for approximately one month, was found and hospitalized, stabilized, and returned to the facility, and had been back at the facility since approximately 01/31/23. LPA reviewed R1’s medication lists which show R1’s psychiatric medication was changed while they were hospitalized. AD stated that on 02/08/23, R1 was last seen in the late morning but could not be found during a room check around noon. AD filed a missing persons report with GGPD on 02/08/23. As of today’s inspection, R1 has not returned to the facility. AD stated that AD followed up with GGPD multiple times since 02/08/23. 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 the facility does not know why R1 left, that there were no events or incidents leading up to R1 leaving, and R1 did not have a change of condition.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2023
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: 02/13/2023
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AD stated that facility staff go around every hour to check on residents and that is how the facility discovered R1 was not present, 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. AD stated that the facility has an elopement protocol which the facility followed during this incident. AD stated that R1’s doctor is recommending that R1 should be relocated to a residential care facility for the elderly with close monitoring after R1 is found. AD stated they will provide LPA with twice weekly updates on R1’s missing persons case and will notify LPA when R1 is found.

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: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2023
LIC809 (FAS) - (06/04)
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