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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005339
Report Date: 10/19/2021
Date Signed: 10/19/2021 11:57:58 AM

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:STEADFAST CHOPIN DRFACILITY NUMBER:
306005339
ADMINISTRATOR:PENALOSA, FRANCINEFACILITY TYPE:
735
ADDRESS:8368 CHOPIN DRTELEPHONE:
(310) 809-3437
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY:6CENSUS: 6DATE:
10/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Kimberly Funelas TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Norman Woodridge conducted a Covid-19 Annual Inspection at the facility. Upon arrival, LPA informed Staff 1 (S1) of the purpose of the visit and was granted entry into the building. LPA and S1 conducted a tour of the inside and outside of the facility, common areas, resident rooms, garage, and kitchen.

LPA discussed and observed the following:

There were 3 staff and 6 clients present at the facility. Client rooms were clean and organized. LPA observed a 2-day supply of perishables and a 7-day supply of nonperishables. LPA observed hygiene products for clients and PPE supplies for the facility. Hallways and walkways were free from obstruction and LPA observed medication and cleaning supplies that were locked up. LPA discussed updated Covid-19 requirements with lead staff, Kimberly Funelas, and reviewed Covid-19 records for clients and staff. LPA also reviewed Covid-19 sign in sheet for visitors. LPA discussed PIN 21-40 ASC: Updated Statewide Visitation, Waiver, and Testing and Vaccination Verification Guidance for Visitors Related to Coronavirus Disease 2019 (Covid-19). A copy of PIN 21-40 was provided.

No deficiencies were noted during the inspection.

An exit interview was conducted with lead staff and a copy of this report was provided.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Norman WoodridgeTELEPHONE: (714) 703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
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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