306003947-5-23-2024-22-AS-EKIM-D5JS2F-20240523132928

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003947
Report Date: 05/23/2024
Date Signed: 05/23/2024 01:30:32 PM

Document Has Been Signed on 05/23/2024 01:30 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	CHESTNUT HOME		FACILITY NUMBER:	306003947
ADMINISTRATOR:	OSCAR R. CACHUELA		FACILITY TYPE:	735
ADDRESS:	440 E. CHESTNUT AVENUE		TELEPHONE:	(714) 283-3455
CITY:	ORANGE	STATE: CA	ZIP CODE:	92867
CAPACITY:	5	CENSUS: 4	DATE:	05/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Annabel Cachuela and Leilani Dagdag		TIME COMPLETED:	01:45 PM

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On May 23, 2024 at 8:40am, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by House Manager (HM) Annabel Cachuela and explained the purpose of the visit..

The facility is licensed to operate for five (5) ambulatory and is a level 4-1 Adult Residential Facility (ARF). The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) bedrooms, two (2) bathrooms, attached garage, living room, dining room, kitchen, an outdoor in-ground pool, and outside covered patio area.

LPA Kim toured indoor and outdoor of the physical plant with HM Cachuela. Administrator (AD) Leilani Dagdag arrived to the facility at 9:19am and joined in middle of the physical indoor and outdoor tour. There is no obstructions on the premises. The in-ground pool is surrounded by a fence that is 72 inches in height and the bars are 4" to 4.5" apart from each other. The pool gate door self-closes and self-latches away from the pool. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each client’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. . All bedrooms were inspected: Client Room 1, Client Room 2, Client Room 3, Client Room 4, Client Room 5 and Staff Room 1. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 110.0 and 117.0 degrees F. A comfortable temperature of 70 degrees F was maintained in the facility.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food and water supply is stored in the garage.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CHESTNUT HOME	FACILITY NUMBER: 306003947
	VISIT DATE: 05/23/2024

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During the visit, LPA Kim observed the facility's infection control practices. LPA Kim observed screening protocols for visitors, staff, and clients, and sanitizing stations in common areas and restrooms. LPA Kim observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. First Aid Kit contained all the necessary elements. The facility has a fire extinguisher that is fully charged, mounted in the kitchen, and serviced in December 5, 2023. The facility has smoke detectors and carbon monoxide detector were operable. The facility conducted a Fire/Safety Drill on March 16, 2024. A working telephone (714-283-3455) remains available.

LPA Kim conducted an audit of client #1-4 service files, and staff #1-4 personnel files that were in order and complete. LPA Kim conducted two (2) staff interviews. All clients were in day program and could not be interviewed. Each client has their own tablet or cell phone for internet access.

No deficiencies were cited during this inspection visit.

An exit interview was conducted, and a copy of this report was provided to Administrator Leilani Dagdag,

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (916) 956-7332
LICENSING EVALUATOR NAME: Edward Kim	TELEPHONE: (714) 293-1237
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC809 (FAS) - (06/04)

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