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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005703
Report Date: 05/24/2023
Date Signed: 05/30/2023 01:42:02 PM

Document Has Been Signed on 05/30/2023 01:42 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: 0DATE:
05/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sarah PaulTIME COMPLETED:
02:30 PM
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On 05/09/2023 , at 11:10 am, Licensing Program Analyst (LPA) Lydia Martinez made an attempted unannounced visit to the facility to conduct a Required - Year inspection. LPA Martinez was told by a gentlemen who stated no one was home and that he was only the Mechanic. LPA Martinez called and spoke to Administrator (AD)Sarah Paul who indicated there are currently no clients in care at this facility. AD Paul indicated they have not been able to be vendored by Orange County Regional Center and she does not know why. AD Sarah Paul indicated she is not available at the moment. LPA told AD she will visit facility at a later date.
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On 05/17/2023, at approximately 3:00 PM, LPA Martinez made a second attempt visit in order to conducted a Required 1 Year inspection. LPA knocked on the door several times and received no answer. LPA contacted Sarah Paul via telephone who stated no one is in the home and is unavailable at the moment to meet LPA. LPA advised Sarah LPA will return at a later date.
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Licensing Program Analyst (LPA) Lydia Martinez made this unannounced visit to the facility to conduct a Required 1 Year inspection. LPA Martinez met with Administrator Sarah Paul, who reiterated there are currently no clients in care at this facility. AD 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 placement's at Aloe Special Care Home, #306001386. The plan is to move 4 of the 6 to Chase Special Care Home upon vendorization.

LPA along with AD Paul toured inside and outside of the facility and the following was observed: Client bedrooms were observed to be spacious and easily accommodate furnishings such as lamps, chair, dresser and a bed. Bathrooms were clean, faucets, showers and toilets were operational. Hot water temperature in client bathroom was within regulatory requirements.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2023
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: 05/24/2023
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Facility currently has no clients residing at the home. AD Paul understands to have the following when clients are moved in: Plenty of linen and hygiene supplies will be provided for number of client's in care; Emergency Phone Numbers and Exit Plan will be updated; Food prep area is clean and organized. Will have food supply in sufficient quantities to meet the regulatory requirements of a 2-day perishables and 7-day non-perishables. Emergency food and water supply will be available. Smoke detectors and carbon monoxide detectors were found to be operational. Fire Extinguisher were charged and mounted. Fire drills will be conducted once a month. Stove burners, microwave, dishwasher, washer, and dryer are operational. Chemicals and sharps will be made inaccessible to the clients. Medications will be centrally stored in a locked hallway closet. LPA observed seating and shaded area for clients and visitors enjoyment in backyard area. LPA noted secured swimming pool area.

First-Aid Kit had all the required elements and Activity Supplies were observed and available. There is a working land line at the facility. The LIC610D, Emergency Disaster Plan to be updated.

AD Paul was reminded to notify the Department within 5 business days of admitting the first client. This notification may be done by phone, mail, email or fax.



Based on LPA's observation during this visit, no deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations. Copy of this report will be sent to the email on file.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
LIC809 (FAS) - (06/04)
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