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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003947
Report Date: 05/30/2024
Date Signed: 05/30/2024 10:34:48 AM

Document Has Been Signed on 05/30/2024 10:34 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CHESTNUT HOMEFACILITY NUMBER:
306003947
ADMINISTRATOR/
DIRECTOR:		OSCAR R. CACHUELAFACILITY TYPE:
735
ADDRESS:440 E. CHESTNUT AVENUETELEPHONE:
(714) 283-3455
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY: 5CENSUS: 4DATE:
05/30/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:06 AM
MET WITH:Cleopatra Cachuela- Licensee/Adminstrator
Hernando Liwanag- Administrator		TIME VISIT/
INSPECTION COMPLETED:
10:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho continued an unannounced Case-Management visit after delivering the findings in connection to Complaint Control Number: 22-AS-20230721111639. The purpose of this visit is to issue deficiencies that were discovered during the investigation mentioned above.

LPA met with Licensee/Administrator Cleopatra Cachuela and Administrator Hernando Liwanag and explained the reason for the visit. On today’s date, LPA observed zero clients and one staff during the visit. The investigation mentioned above revealed that the facility did not meet the Reporting Requirements as mandated per the Title 22 80061:

1. C1 refusing medications on June 5, 6, and 13, 2023.
2. Renovations that began approximately July of 2023
3. Client #1 (C1) eloped three times on three different days: July 18, 2023, July 19, 2023, and July 20, 2023

In addition, Staff #3 (S3) did not immediately telephone emergency response (9-1-1) which resulted in the death of C2. The investigation also revealed that 1:1 Program Support was not in place as required per the Individual Program Plan (IPP) dated May 15, 2023, as one out of the three facility staff indicated that C1 had expressed feeling bored.

Therefore, deficiencies are being cited as per the Title 22, Division 6, Chapter 6 of the California Code of Regulations. See the attached LIC809-Ds.

An exit interview was conducted with Licensee/Administrator Cleopatra Cachuela and Administrator Hernando Liwanag, and a copy of this report including the LIC809Ds, LIC811s, and the appeal rights were provided at the end of the visit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2024
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 05/30/2024 10:34 AM - It Cannot Be Edited


Created By: Jessica Cho On 05/30/2024 at 10:09 AM
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: CHESTNUT HOME
FACILITY NUMBER: 306003947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/31/2024
Section Cited
CCR
80075(a)

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80075 Health Related Services (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services…
This requirement was not met as evidenced by:
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Administrator stated that staff will be trained to call 911 immediately in the case of an emergency and to forward proof of all training to LPA via email by POC due date.
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Based on S3’s interview, staff did not immediately telephone 9-1-1 but called the facility administrator when C2’s health and safety was in imminent danger which poses an immediate Health or Safety risk to persons in care.
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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:Lourdes Montoya
LICENSING EVALUATOR NAME:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/30/2024 10:34 AM - It Cannot Be Edited


Created By: Jessica Cho On 05/30/2024 at 10:10 AM
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: CHESTNUT HOME
FACILITY NUMBER: 306003947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/06/2024
Section Cited
CCR
80061(b)(1)(E)

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80061 Reporting Requirements (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following: (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
This requirement was not met as evidenced by:
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Facility to submit incident reports pertaining to the incidents addressed in the report and to submit an Acknowledgement of Understanding for the said deficiency to LPA via email by POC due date.
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Based on interviews and record review, facility did not comply with the section cited above which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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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:Lourdes Montoya
LICENSING EVALUATOR NAME:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024


LIC809 (FAS) - (06/04)
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