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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005703
Report Date: 06/06/2022
Date Signed: 06/06/2022 02:52:48 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/06/2022 02:52 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:CHASE SPECIAL CARE HOMEFACILITY NUMBER:
306005703
ADMINISTRATOR:CHASE, DAVIDFACILITY TYPE:
735
ADDRESS:17601 SANTA MONICA CIRCLETELEPHONE:
(714) 964-9479
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: DATE:
06/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:32 PM
MET WITH:Sarah Paul, AdministratorTIME COMPLETED:
02:52 PM
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 On today's date at 8:32am Licensing Program Analyst (LPA) Rosie Quiroz made an attempted unannounced visit to facility to conduct an Annual Required inspection visit. LPA Rosie Quiroz called and spoke to Administrator (AD)Sarah Paul who indicated there are currently no clients in care at this facility. AD Sarah Paul indicated "Due to facility not being vendored by Orange County Regional Center, we haven't been able to move the clients to this facility. Currently have 6 clients at Aloe Special Care Home, Facility #306001386. The plan is to move 4 of 6 clients from Aloe Special Care Home to Chase Special Care Home upon vendorization from Orange County Regional Center."
AD Sarah Paul indicated she would be present at facility in the afternoon. LPA Quiroz returned to facility to conduct Annual required inspection.

LPA Quiroz was granted entry by AD Sarah Paul and discussed the purpose of the visit. On or about 1:54pm, LPA Quiroz along with AD Sarah Paul began tour of inside and outside of facility. The Facility temperature was recorded to be 75 degrees fahrenheit.
All restrooms observed to have a supply of soap, appeared to be clean and water temperatures were recorded to be within 114 degrees Fahrenheit. LPA Quiroz inspected resident’s bedrooms and appeared to be clean. All bedrooms observed to have all required components. LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food, water in garage and kitchen area readily available for staff and clients. AD Sarah Paul indicated the PPE was transferred to Aloe Special Care Home to utilize. LPA Quiroz toured the outside of the facility and observed seating and shaded area for clients and visitors enjoyment in backyard area. LPA Quiroz observed locked and secured swimming pool area. The facility has completed the LIC 808 Mitigation Plan. The LIC 808 plan was received by the Department on July 10, 2021. During today's visit, LPA Quiroz reviewed and approved LIC 808 Mitigation Plan dated July 10, 2021.
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SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2022
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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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: CHASE SPECIAL CARE HOME
FACILITY NUMBER: 306005703
VISIT DATE: 06/06/2022
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LPA Quiroz was informed that "all clients and staff have had their COVID-19 vaccinations and first Booster."

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.



During today's visit, LPA Quiroz provided Consultation on Title 22 and COVID-19 Infection control throughout today's visit. AD Sarah Paul will inform CCL upon vendorization from Orange County Regional Center at this facility.

This report was reviewed with AD Sarah paul, and a copy of this report was provided at exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
LIC809 (FAS) - (06/04)
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