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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006424
Report Date: 05/06/2024
Date Signed: 05/06/2024 09:10:20 AM

Document Has Been Signed on 05/06/2024 09:10 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/
DIRECTOR:
DANG, ROSIEFACILITY TYPE:
740
ADDRESS:10461 CHAPMAN AVENUETELEPHONE:
(714) 595-9880
CITY:GARDEN GROVESTATE: CAZIP CODE:
92840
CAPACITY: 6CENSUS: 0DATE:
05/06/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Rosie DangTIME VISIT/
INSPECTION COMPLETED:
09:25 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. This is the second pre-licensing inspection. Please see LIC809 dated 03/06/2024.
During the initial 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. Since the initial pre-licensing inspection, AP corrected the water temperature, obtained and installed lamps in the resident bedrooms, and obtained a new fire clearance which includes the second floor and also changes the designations of certain rooms. During today’s inspection, LPA toured the facility with AP, observed the water temperature tested between 112.5 degrees F and 117 degrees in the three resident bathrooms, observed lamps in all resident bedrooms, and observed the new fire clearance includes the second floor and that the applicant is following the new fire clearance. LPA confirmed that the issues noted during the initial pre-licensing inspection have been addressed.
LPA explained the process of this application and about the post licensing inspection once the facility is licensed. AP was informed today that the facility is ready for licensure and final approval will be processed by the CAB supervisor in Sacramento. Component III was completed during the initial pre-licensing inspection. 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: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2024
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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