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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006132
Report Date: 10/09/2024
Date Signed: 10/09/2024 03:55:08 PM

Document Has Been Signed on 10/09/2024 03:55 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:BEVERLY HOMEFACILITY NUMBER:
306006132
ADMINISTRATOR/
DIRECTOR:		CHEA, PAULFACILITY TYPE:
735
ADDRESS:1183 W. CHATEAU AVETELEPHONE:
(714) 215-4396
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 6CENSUS: 2DATE:
10/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:47 PM
MET WITH:Paul Chea- AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of following up on the death of Client #1 (C1) which occurred while client was under the care of another licensed facility on October 7, 2024.

During today's visit, LPA interviewed Administrator Paul Chea, C1's Behavior Specialist, and two caregivers on duty. LPA reviewed and obtained copies of the following documentation: Client Roster, Personnel Report Summary, Medication Administration Records, Physician's Report, IPPs, CDER, and other pertinent records.

LPA toured the interior and exterior of the facility. LPA observed the facility's utility to be working. LPA observed three roaches at the time of the visit. LPA received a copy of the service agreement with Western Exterminator which is to begin October 16, 2024 per Administrator. Facility will be serviced on a quarterly basis. Facility maintains a 2-day supply of perishable and a 7-day supply of non-perishable food in the kitchen and garage. Medications, sharps, toxins, and cleaning supplies were secured and inaccessible to the clients. Certificate of liability insurance remains current.

During today's visit, no imminent health and safety violations were observed and no deficiency is being cited. A Technical Violation is being issued.

An exit interview was conducted with Administrator Paul Chea, and a copy of this report was provided at the end of the visit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2024
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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