331880524-11-18-2024-18-AS-FSAS-DB5RQU-20241118121408

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880524
Report Date: 11/18/2024
Date Signed: 11/18/2024 12:14:31 PM

Document Has Been Signed on 11/18/2024 12:14 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	CHAP RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	331880524
ADMINISTRATOR/ DIRECTOR:	CHAP, SOKHEA		FACILITY TYPE:	735
ADDRESS:	29484 CAMINO CRISTAL		TELEPHONE:	(951) 443-5087
CITY:	MENIFEE	STATE: CA	ZIP CODE:	92584
CAPACITY: 4		CENSUS: 3	DATE:	11/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:15 AM
MET WITH:	Sokhea Chap Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:15 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

Licensing Program Analysts (LPAs) Ferrer Sabarias and Abdoulaye Zerbo conducted an unannounced annual required visit. Upon entry, LPAs met with Sokhea Chap, Administrator, and informed her of the purpose of the visit. At the time of the visit, there were two (2) staff members and no residents present.

Facility Overview: The facility is a two-story home with four (4) bedrooms for clients, two bedrooms for staff and two (2) bathrooms, including an attached garage. There is no pool or firearms on the premises.

Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance and are securely locked in a cabinet and inaccessible to residents. The facility’s infection control plan was reviewed and found to meet department requirements.

Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. The outdoor area was free of hazards. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked and inaccessible to residents. Both the smoke detector and carbon monoxide detector were operational, fire extinguisher is observed to expire on 8/27/25 and the hot water temperature was 105.4°F. LPAs observed the kitchen and dining area not to be cleaned and unsanitary. A citation will be issue.

Continued on LIC809-C...

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Ferrer Sabarias
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CHAP RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 331880524
	VISIT DATE: 11/18/2024

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
26
27
28
29
30
31
32

Continued from LIC809…

Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable food. LPAs observed multiple food items in the pantry to be expired. A citation will be issue.

Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate that expire on 8/6/2026.

Record Review and Resident/Staff Files: LPAs reviewed files for two staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Three resident files were reviewed and contained all required documentation.

Health-Related Services/Incidental Medical Services: All resident medications were securely locked. LPAs reviewed medications for three (3) residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for.

Disaster Preparedness: LPAs reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 10/1/2024, which met department requirements. All facility exits were clear of obstructions.

An exit interview was conducted, this report was reviewed, and a copy was provided to Sokhea Chap Administrator along with the appeal right..

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Ferrer Sabarias
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3

Document Has Been Signed on 11/18/2024 12:14 PM - It Cannot Be Edited

Created By: Ferrer Sabarias On 11/18/2024 at 11:52 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: CHAP RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 331880524
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 out of 2 kitchen and dining are which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/02/2024
	Plan of Correction
1 2 3 4	LIcensee will take a picture and send the proof of correction by POC due date.

Type B

Section Cited

CCR

80076(a)(7)

Food Service

(a) In facilities providing meals to clients, the following shall apply: (7) Commercial foods shall be approved by appropriate federal, state and local authorities. All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 6 out of 6 food items which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/02/2024
	Plan of Correction
1 2 3 4	LIcensee will check the inventory and discard all expired food and send the proof of correction by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Rikesha Stamps

LICENSING EVALUATOR NAME:

Ferrer Sabarias

LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3