306002370-8-31-2023-22-AS-DLMN-CV8VWG-20230831164755

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002370
Report Date: 08/31/2023
Date Signed: 08/31/2023 04:48:09 PM

Document Has Been Signed on 08/31/2023 04:48 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	CHARIS CHATEAU, INC		FACILITY NUMBER:	306002370
ADMINISTRATOR:	MARIE NOEL		FACILITY TYPE:	735
ADDRESS:	10231 DEWEY DRIVE		TELEPHONE:	(714) 636-6595
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92840
CAPACITY: 5		CENSUS: 4	DATE:	08/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Marie Noel - Administrator		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Dwayne Mason Jr. and Claudia Gutierrez arrived at Charis Chateau to conduct an unannounced Required 1 Year Inspection. At 1:35pm, LPAs Mason and Gutierrez were greeted and granted entry by Caregiver Rodrigo Domine. Administrator AD Marie Noel arrived at 2:00pm. Upon record review LPAs noted that last disaster drill was conducted on July 6, 2023. Structure: The facility is a one-story home with four resident bedrooms, 2 bathrooms, living room, kitchen, staff bedroom, office, an attached two car garage and a backyard with a pool. LPAs observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the living room area. The fireplace screen is not operational. A deficiency was issued on today’s date. LPAs observed the door leading to the backyard to be in disrepair. There is a back yard with one exit gate on the side of the house. There is one shaded seating area in the backyard. LPAs observed rusted and unused items in the pool storage area. Client Bedrooms All resident bedrooms had the required furnishings. LPAs observed all resident beds had linens and blankets. LPA observed all windows were screened. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored and locked in the garage. Medications, First-Aid Kit & Book: Medication will be stored in a locked cabinet. First aid kit is stored with the medication. The first aid kit has all the required elements. Resident & Staff Files: Records will be kept locked in storage cabinet located in the Office. LPAs reviewed 4 out of 4 client files and 6 staff files. LPAs interviewed 3 staff and 3 clients. Fire Extinguisher: The fire extinguishers is fully charged.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

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 08/31/2023 04:48 PM - It Cannot Be Edited

Created By: Dwayne L Mason On 08/31/2023 at 03:48 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: CHARIS CHATEAU, INC	FACILITY NUMBER: 306002370
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) 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 met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, the licensee did not comply with the section cited above in 5 instances: backyard screen door gets stuck when trying to open it presenting a fire hazard, stove is missing an igniter knob, sink in bath1 is loose, fireplace screen is broken, there is a storage area accessible to clients near the pool. This area has a rusted wagon and tricycle that are hazardous to clients. These instances pose a potential safety risk to persons in care.
	POC Due Date: 09/29/2023
	Plan of Correction
1 2 3 4	Facility will attempt to repair the backyard sliding door, if it cannot be repaired they will replace. Facility will replace the lost stove igniter knob. Facility will attempt to repair the sink, if it cannot be repaired, they will replace. Facility will replace fireplace screen. Facility removed hazardous items in the pool storage area during the facility visit. LPA will conduct an additional visit to verify completion of POC

Type B

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs hot water measurements, the licensee did not comply with the section cited above. Hot water dispensed measured 128.4 degrees Fahrenheit which poses a potential safety risk to persons in care.
	POC Due Date: 09/29/2023
	Plan of Correction
1 2 3 4	AD will contact a professional outside of the facility to inspect the water heater. AD will keep a daily log of hot water temperatures to ensure consistency. LPA will make an additional visit to verify completion of the POC.

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:

Dwayne L Mason

LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CHARIS CHATEAU, INC	FACILITY NUMBER: 306002370
	VISIT DATE: 08/31/2023

NARRATIVE

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Reading Material, Games, Equipment & Materials:
The facility has books, magazines, board games, and exercise equipment that will be kept in the living room

Bedrooms Staff:
One bedroom will be occupied by staff.

Bathrooms:
All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 128.1 degrees Fahrenheit. LPAs observed the sink in Bathroom 1 to be loose. A deficiency is being given on this day

Linens & Hygiene Supplies:
A supply of extra linen was stored in the hallway storage. Hygiene supplies are stored in the garage.

Emergency Phone Numbers, Exit Plan & Menu:
Posted and available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menu was posted and visible.

Food Service:
There is a supply of 2-day perishable and 7-day of non-perishable food on hand.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Gas 4 burner stove with 1 oven, 1 refrigerator, dish washer, microwave, washer, and dryer are operational. The stove is in disrepair due to one of the igniters missing it’s knob.

Based on the observations made during today's visit, two deficiencies are being cited as per Title 22 Division 6 Chapter 2 of the California Code of Regulations. An exit interview was conducted with Administrator Marie Noel, and a copy of this report and appeal rights were provided during this visit.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC809 (FAS) - (06/04)

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