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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006424
Report Date: 03/06/2024
Date Signed: 03/06/2024 10:16:53 AM

Document Has Been Signed on 03/06/2024 10:16 AM - 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:CHAPMAN ROSE, INCFACILITY NUMBER:
306006424
ADMINISTRATOR:DANG, ROSIEFACILITY TYPE:
740
ADDRESS:10461 CHAPMAN AVENUETELEPHONE:
(714) 595-9880
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 6CENSUS: 0DATE:
03/06/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Rosie DangTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Sean Haddad conducted this announced inspection for the purpose of conducting a pre-licensing inspection. LPA met with Applicant (AP) Rosie Dang, discussed the purpose of the inspection, and toured the facility. Facility is to operate a Residential Care Facility for the Elderly. Application was submitted to Community Care Licensing on 09/25/2023. This is an initial application with no residents in care.

During the inspection, LPA and AP observed the following: Structure: this is a two-story home. Facility is a 6-bedroom, 3-bathroom, 2 story house with an attached garage that is being used for storage. There is a back yard with a patio cover for the residents. Facility telephone number is (714) 583-8174. Resident Bedrooms: the 3 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: there are no staff bedrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 130 F degrees. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers and Exit Plan: reviewed. Food Service: 7 days nonperishable food supply reviewed and AP stated they will obtain 2 days perishable food supply prior to accepting residents. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: inspected. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the garage. Medication cabinet is locked. First-Aid Kit and Activity Supplies: observed and available. Resident & Staff Files: this is an initial inspection and LPA observed storage space for resident and staff files. Fire clearance was approved by Orange County Fire Authority on 12/11/23. Backyard: backyard exit gate is operational and unlocked. Backyard has shaded area for outdoor activities and sufficient seating for residents. Component III was completed with AP during today’s inspection. AP will obtain liability insurance once the application is approved.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2024
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CHAPMAN ROSE, INC
FACILITY NUMBER: 306006424
VISIT DATE: 03/06/2024
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During the inspection, LPA and AP observed the following: the water temperature in the east resident bathroom tested at 130 F degrees. The resident bedrooms did not have lamps. The facility has a second floor which is not reflected on the floor plan. AP stated they will correct these issues and notify LPA once they have been corrected. Regarding the fire clearance, AP stated they will request a new fire clearance clearing the “Reception/Staff Office” room as either a resident bedroom or staff bedroom and clearing the second floor for 2 staff bedrooms, a bathroom, and a small common area. AP stated that the new facility sketch will reflect these changes and include the second floor.

During the inspection, LPA explained the process of this application and about the post licensing inspection once the facility is licensed. AP was informed the item(s) listed above must be completed for the facility to meet Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to AP.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
LIC809 (FAS) - (06/04)
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