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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003947
Report Date: 05/16/2022
Date Signed: 05/16/2022 10:34:07 AM

Document Has Been Signed on 05/16/2022 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CHESTNUT HOMEFACILITY NUMBER:
306003947
ADMINISTRATOR:OSCAR R. CACHUELAFACILITY TYPE:
735
ADDRESS:440 E. CHESTNUT AVENUETELEPHONE:
(714) 283-3455
CITY:ORANGESTATE: CAZIP CODE:
92867
CAPACITY: 5CENSUS: 5DATE:
05/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:17 AM
MET WITH:Annabel Cachuela, Hernando Liwanag TIME COMPLETED:
10:43 AM
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Licensing Program Analysts (LPA) Edward Tapia made an unannounced required annual inspection in this facility. LPA met with staff Annabel Cachuela and stated the purpose of this visit. Administrator Hernando Liwanag arrived during the visit at 8:45 AM and provided assistance.

The facility is a single level structure and licensed for five ambulatory clients. This facility offers a Level IV-I service.

At about 8:17 AM, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed two clients in care and one staff member on the duty. LPA toured the interior and exterior portions of the facility. There were five private client rooms and one private staffroom. Residents rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide alarms were tested to be operational. Bathroom (1) was observed to be in good repair and provided with grab bars and hot water was measured at 118.4 degrees Fahrenheit. Bathroom (2) was observed to be in good repair and provided with grab bars and hot water was measured at 111.3 degrees Fahrenheit. Facility met the minimum two day supply of perishable and seven day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to clients in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. LPA did notice a ladder was observed and removed so residents could not access it. LPA did notice a pool in the backyard and it was kept locked so residents could not access it. There was a 2 car garage attached to the facility with an operating washer and dryer, emergency supplies and emergency food. LPA did a closer inspection of the emergency food and notice most of it was expired. LPA made Administrator aware of this fact and Administrator will replace emergency food.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2022
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: CHESTNUT HOME
FACILITY NUMBER: 306003947
VISIT DATE: 05/16/2022
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Kitchen was in good repair with knifes kept locked. LPA did notice a screwdriver in kitchen area and reminded that tools should be kept locked. LPA also notice that 4 stove burner had only 2 burners attached. Administrator stated clients will pull burners when not in use due to behaviors. LPA make it clear that 4 burners need to be operational and that a cover can be placed when not in use. LPA Tapia reviewed the COVID 19 mitigation plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed. No citation was issued. Three advisories were issued today.

LPA Tapia conducted an exit interview with Administrator Hernando Liwanag and a copy of this report was left at the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022
LIC809 (FAS) - (06/04)
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