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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005339
Report Date: 08/23/2022
Date Signed: 08/23/2022 03:55:31 PM

Document Has Been Signed on 08/23/2022 03:55 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 DRFACILITY NUMBER:
306005339
ADMINISTRATOR:PENALOSA, FRANCINEFACILITY TYPE:
735
ADDRESS:8368 CHOPIN DRTELEPHONE:
(310) 809-3437
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 6DATE:
08/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Kimberly FunelasTIME COMPLETED:
04:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced case management visit at Steadfast Chopin Dr. LPA was greeted, granted entry by staff, and explained the reason for the visit. LPA Haley spoke with Administrator Susie Abella via telephone call.

The purpose of today's visit was to conduct a Case Management visit to discuss an Unusual Incident Report (LIC 624) that was sent to the Orange County Adult and Senior Care Regional Office August 19, 2022.

On today's visit LPA Haley conducted an interview with Administrator Susie via telephone regarding the incident involving Client 1 (C1) on August 13, 2022. LPA Haley reviewed C1 file and received copies of the most recent Physicians Report, Preplacement Appraisal, and Identification and Emergency Information for C1.

LPA Haley left a copy of the COVID 19 informational flyer from the California Department of Public Health dated June 30, 2022.

No deficiencies are being cited during today's Case Management visit. An exit interview was conducted and a copy of this report and LIC 811 was provided.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2022
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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