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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005703
Report Date: 06/14/2024
Date Signed: 06/14/2024 04:04:23 PM

Document Has Been Signed on 06/14/2024 04:04 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:
06/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:25 PM
MET WITH:David ChaseTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At around 2:20 PM, LPA Tea was greeted and granted entry into the facility by Administrator (AD) David Chase and explained the reason for the visit. Facility is licensed for six clients, two may be ambulatory and four may be non-ambulatory. Currently there are no clients in care during today's visit. AD Chase indicated that there are no clients under care due to Orange County Regional Center not vendoring the facility. The administrator hopes to move his clients from another facility, Aloe Special Care Home #306001386 to Chase Special Care Home.

LPA Tea along with the Administrator toured the facility at 2:33 PM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of 3 client bedrooms, which all are shared, 1 staff bedroom, 2 full bathrooms, living room, dining room, and kitchen. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms to be operational. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured at 124.5 degrees F and LPA advised the administrator that water temperature needs to be in the required temperature range when clients are present. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. Kitchen was inspected. Non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen cabinet. LPA also observed toxin substances inaccessible to clients in care, locked and secured in a kitchen cabinet and garage. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating with shade and the exit gate is self latching and operational. The backyard has a pool that is gated. LPA observed emergency supplies in the garage.



Continuation of the annual report on LIC809-C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CHASE SPECIAL CARE HOME
FACILITY NUMBER: 306005703
VISIT DATE: 06/14/2024
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Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with Administrator, David Chase and a copy of this report LIC809, 809-C, LIC9102 was read and provided to the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024
LIC809 (FAS) - (06/04)
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