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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006592
Report Date: 12/17/2024
Date Signed: 12/17/2024 09:47:59 AM

Document Has Been Signed on 12/17/2024 09:47 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:CHESTNUT COVEFACILITY NUMBER:
306006592
ADMINISTRATOR/
DIRECTOR:		BUGASTO, MYRNAFACILITY TYPE:
740
ADDRESS:1225 E CHESTNUT ST.TELEPHONE:
(714) 306-3523
CITY:ANAHEIMSTATE: CAZIP CODE:
92805
CAPACITY: 6CENSUS: 0DATE:
12/17/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Macrina JaboneroTIME VISIT/
INSPECTION COMPLETED:
10:05 AM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA met with Licensee Macrina Jabonero. An application to operate a Residential Care Facility for the elderly (RCFE) for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden residents was received by CCL on June 13, 2024.

Structure:
The facility is a one-story house with four resident bedrooms, two staff rooms, three bathrooms, one living room, one kitchen, and one dining room. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the entranceway. There is a backyard with an exit gate each side of the house. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard.

Resident Bedrooms
All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets.

Signal system
There is a signal system. Signal system generates an audible sound and identifies the bedroom of each resident.

Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked underneath the kitchen sink.

Resident & Staff Files:
Records will be kept in a locked cabinet.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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: CHESTNUT COVE
FACILITY NUMBER: 306006592
VISIT DATE: 12/17/2024
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Medications, First-Aid Kit & Book:
Medication will be stored in a locked cabinet. First aid kit is stored in one of the staff rooms and has all the required elements.

Pool/Jacuzzi:
No bodies of water were observed.

Fire Extinguisher:
Fire extinguisher is fully charged.

Reading Material, Games, Equipment & Materials:
The facility has reading books, board games, and other recreational materials for resident use stored in a cabinet in the dining room.

Fire clearance:
Was approved by a fire inspector of the Anaheim Fire Department on July 18, 2024. Special conditions noted, “Bedridden in room #4.”

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements.

Bedrooms Staff:
There are two staff rooms.

Bathrooms:
All bathrooms have working plumbing. Hot water measured between 115.1- and 120.1-degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen was stored in a closet.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: CHESTNUT COVE
FACILITY NUMBER: 306006592
VISIT DATE: 12/17/2024
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Emergency Phone Numbers, Exit Plan & Menu:
Posted and available, means of exiting, and emergency phone numbers. Food menu is available for review in menu binder stored with resident activity supplies.

Food Service:
A supply of 2-day perishable and 7-day of non-perishable food will be maintained on hand.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Gas burner stove, dishwasher, refrigerator, microwave oven, washer, and dryer are operational.

The Licensee was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. An exit interview was conducted and a copy of this report was provided to Licensee.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC809 (FAS) - (06/04)
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