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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005339
Report Date: 01/09/2025
Date Signed: 01/09/2025 12:10:05 PM

Document Has Been Signed on 01/09/2025 12:10 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: 3DATE:
01/09/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:DSP Marline AgraanTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On January 9, 2025, at 8:00am, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced Case Management Visit to follow-up on a death report received from the facility. LPA Kim was greeted and granted entry by Administrator (AD) Susierose Abella and LPA Kim explained the purpose of the visit. AD Abella could not stay for the visit and Direct Support Professional (DSP) Marline Agraan was given permission to sign the report in behalf of the facility.

During today’s visit, LPA conducted a health and safety check, and there were no imminent health/safety concerns observed. Facility maintained at a comfortable temperature for the residents in care. LPA obtained LIC 500, LIC 9020, and C1’s records which includes the Physician’s Report, Admission’s Agreement, Emergency Information, Consent Forms, Appraisal and Needs/Service Plan, and other pertinent documents. LPA interviewed AD Susierose Abella, Licensee, two staff members, and the Responsible Person of the client.

No deficiencies were observed during this visit.

An exit interview was conducted, and a copy of this report was provided to the Direct Support Professional Marline Agraan.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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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