306005339-7-8-2022-22-AS-JHAY-CG5SC6-20220708134458

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005339
Report Date: 07/08/2022
Date Signed: 07/08/2022 01:45:16 PM

Document Has Been Signed on 07/08/2022 01:45 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:	STEADFAST CHOPIN DR		FACILITY NUMBER:	306005339
ADMINISTRATOR:	PENALOSA, FRANCINE		FACILITY TYPE:	735
ADDRESS:	8368 CHOPIN DR		TELEPHONE:	(310) 809-3437
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY: 6		CENSUS: 2	DATE:	07/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Susierose Abella		TIME COMPLETED:	01:49 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. Staff called the Administrator (AD) Susierose Abella arrived and was present for the visit. AD Abella has a current administrators certificate that expires 8/18/22.

At 11:18 AM LPA Haley began the tour of the facility. There were two clients, two staff and AD Abella present during the visit. LPA Haley was screened and temperature checked at the entrance of the facility. LPA Haley observed a screening station set up with a temperature thermometer, temperature log, and pre screening questionnaire. Right near the entrance of the facility there is a locked medication closet, first aid kit, surgical mask and other supplies.

Five of six client bedrooms were clean, organized, and had all necessary requirements. There was one vacant client bedroom with only a dresser. Currently that bedroom is not being occupied. In client bathrooms #1 hot water temperature was measured at 105 degrees Fahrenheit. At 11:27 AM LPA Haley observed rust present in the shower area in client bathroom #1. LPA Haley advised AD Abella of keeping the shower clean and sanitary at all times. Bathroom #2 is used by staff, and remains locked; however, clients are allowed to use bathroom #2 when staff is present. In bathroom #2 hot water temperature was measured at 113.7 degrees Fahrenheit.

In the locked garage, LPA Haley observed an emergency food and water supply, as well as emergency supplies for all clients prepared and ready to go. All hazardous chemicals and cleaning materials are kept in a locked cabinet.

Continued on LIC 809C Dated 7/8/22

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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: STEADFAST CHOPIN DR	FACILITY NUMBER: 306005339
	VISIT DATE: 07/08/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The kitchen area is secured by a child safety gate to keep clients out. All knives are kept in a locked in a tool box near the stove. All burners on the stove were operational. LPA Haley observed a two day supply of perishable food items and a seven day supply of nonperishable food items. In the dining room there is a locked cabinet with an additional supply of PPE: face shields, hand sanitizer, gloves, hand wipes and gowns. LPA Haley observed a fire extinguisher charged and mounted above the sink.

The back yard area had clear walkways that were free of clutter and debris. Self closing and self latching exit gates were observed on both sides of the yard. LPA Haley observed at shaded area with a table and chairs. While inspecting the back yard, at 11:44 AM LPA observed and old dishwasher, some bed frames or railing, and some other metal framing that is no longer being used. LPA spoke with AD Abella about the importance of keeping the facility clean and free of clutter. AD Abella stated she will have the items removed as soon as possible.

No bodies of water were observed. Smoke detectors were tested and were operational.

Deficiencies are being cited under California Code of Regulations, Title 22, Division 6. An exit interview was conducted. A copy of this report along with the appeal rights were provided to AD Susierose Abella.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 07/08/2022 01:45 PM - It Cannot Be Edited

Created By: Jerome Haley On 07/08/2022 at 01:12 PM

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: STEADFAST CHOPIN DR	FACILITY NUMBER: 306005339
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087

80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary, and in good repair at all times for the safety and well being of clients, employees and visitors. This requirement is not met as evidenced by: rust present in the shower area of client bathroom #1 and the old dishwasher and other metals present in the backyard.
	Deficient Practice Statement
1 2 3 4	Based on observation and interview with Administrator Susierose Abella, the licensee did not comply with the section cited above which poses a potential health, and safety risk to persons in care.
	POC Due Date: 07/15/2022
	Plan of Correction
1 2 3 4	Licensee will provide pictures of the rust removed from the shower area in client bathroom #1 and pictures of the clutter removed from the back yard area.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Luz Adams

LICENSING EVALUATOR NAME:

Jerome Haley

LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3