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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005703
Report Date: 06/12/2024
Date Signed: 06/14/2024 04:03:16 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/14/2024 04:03 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:CHASE SPECIAL CARE HOMEFACILITY NUMBER:
306005703
ADMINISTRATOR/
DIRECTOR:		CHASE, DAVIDFACILITY TYPE:
735
ADDRESS:17601 SANTA MONICA CIRCLETELEPHONE:
(714) 964-9479
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 0DATE:
06/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Sarah PaulTIME VISIT/
INSPECTION COMPLETED:
01:45 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 today's date at 1:05 PM Licensing Program Analyst (LPA) Michael Tea made an attempted unannounced visit to facility to conduct an Annual Required inspection visit. LPA Tea called and spoke to Administrator (AD) Sarah Paul who indicated there are currently no clients in care at this facility due to Orange County Regional Center not able to vendor their facility. She said David Chase, the licensee and herself are not available today for the annual inspection.

LPA Tea informed AD that he will attempt to visit again soon and that someone has to be here in person for the annual inspection or else the facility will be cited. LPA asked AD to email a copy of the facilities LIC-500 form on COB of June 13, 2024.

This report was reviewed with the Administrator David Chase and a copy of this report was provided to the facility at the time of exit interview for the second attempted annual inspection on June 14, 2024.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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 1