<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005339
Report Date: 10/04/2024
Date Signed: 10/04/2024 05:07:08 PM

Document Has Been Signed on 10/04/2024 05:07 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:STEADFAST CHOPIN DRFACILITY NUMBER:
306005339
ADMINISTRATOR/
DIRECTOR:		PENALOSA, FRANCINEFACILITY TYPE:
735
ADDRESS:8368 CHOPIN DRTELEPHONE:
(310) 809-3437
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 4DATE:
10/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:House Manager- Kimberly FunelasTIME VISIT/
INSPECTION COMPLETED:
05:15 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
On October 4, 2024, at 1:00pm, 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) Kimberly Funelas and Administrator (AD) Susierose Abella.

The facility is licensed to operate for four (4) ambulatory clients and two (2) nonambulatory clients. The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) client bedrooms, one (1) Staff bedrooms, two (2) bathrooms, living area, dining area, kitchen, outdoor covered patio area, and an attached garage.

LPA Kim toured inside and outside of the physical plant with HM Funelas. There were no bodies of water or obstructions on the premises. 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. The Client’s rooms were inspected: Client Room 1, Client Room 2, Client Room 3, Client Room 4, Client Room 5, and Client Room 6. The water temperature measured between 105.0 degrees F to 116.0 degrees F. A comfortable temperature of 75 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, emergency water, and emergency supplies were stored in the garage. The facility has one (1) fire extinguisher that is charged, mounted in kitchen, and serviced on August 12, 2024.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: STEADFAST CHOPIN DR
FACILITY NUMBER: 306005339
VISIT DATE: 10/04/2024
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
During the visit, LPA Kim observed the facility's infection control practices and plan of operation. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were operable. A working telephone (714-752-6022) remains available. Emergency drills are conducted quarterly.

LPA Kim conducted an audit of four (4) client files (C1-C4), four (4) staff files (S1-S4), and medication and medication administration review that were all in order and complete. LPA Kim conducted one (1) client interview and three (3) staff interviews.

Deficiencies were cited during this visit as per Title 22 Division 6 Chapter 1 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report and appeal rights were provided to House Manager Kimberly Funelas.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/04/2024 05:07 PM - It Cannot Be Edited


Created By: Edward Kim On 10/04/2024 at 04:52 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: 10/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building 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:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed bathroom #2 sink gets clogged when water is running.This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
1
2
3
4
Licensee states they wil fix the clog and send proof of the sink being operational to CCLD via email to edward.kim@dss.ca.gov by POC due date October 18, 2024.
Type B
Section Cited
CCR
80075(g)
Health-Related Services
(g) If the facility has no medical unit on the grounds, first aid supplies shall be maintained and be readily available in a central location in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed the facility does not have an approved current edition of the First Aid Manual.This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
1
2
3
4
Licensee stated they will send proof of completed POC to CCLD via email to edward.kim@dss.ca.gov by POC due date October 18, 2024.
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:Lourdes Montoya
LICENSING EVALUATOR NAME:Edward Kim
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3