306003934-11-16-2021-22-AS-KCHN-C8U38Q-20211116170154

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003934
Report Date: 11/16/2021
Date Signed: 11/16/2021 05:02:09 PM

Document Has Been Signed on 11/16/2021 05:02 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:	CHATEAU ST. MARK HOMES 3		FACILITY NUMBER:	306003934
ADMINISTRATOR:	ANICIA LOPEZ		FACILITY TYPE:	735
ADDRESS:	1621 S. IVANHOE STREET		TELEPHONE:	(714) 758-3655
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY: 6		CENSUS: 5	DATE:	11/16/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	03:50 PM
MET WITH:	Martin Lopez, Administrator		TIME COMPLETED:	05:15 PM

NARRATIVE

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This unannounced case management visit is conducted by Licensing Program Analyst (LPA), Kathrina Chin to follow up on an incident on Self Injurious Behavior(SIB) and suicidal thoughts was reported to Community Care Licensing on 11/15/2021. LPA arrived at facility and met with three caregivers, Alex Navarro, Helen Balbalang, and Marissa Aquino and spoke to Martin Lopez, Administrator.

Mr. Martin stated that resident 1 was admitted on July 2019 and left on January 2021 to move back with her mother. On June 8, 2021, resident was re-admitted to the facility. On November 14, 2021, resident 1 displayed self injurious behavior by punching herself and was suicidal. The CAT Team arrived that day on 11/14/2021 at 9:30 AM. Mr. Martin brought resident to Anaheim Global Medical Center and resident stated that she wanted to receive treatment at the hospital and a voluntary hold was done. Resident 1 was admitted to the hospital and remain at the hospital as of today. Mr. Martin stated that a 30 day notice was served to the resident on October 2021. Mr. Martin stated that he would like to request a 3 day eviction and he will send all the documents to the licensing office.

At this time, based on the information available, there are no deficiencies being cited per Title 22, Division 6 of the California Code of Regulations.

An exit interview interview was conducted and a copy of this report was provided to the facility.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kathrina Chin
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021

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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