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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004811
Report Date: 06/10/2026
Date Signed: 06/10/2026 05:46:18 PM

Document Has Been Signed on 06/10/2026 05:46 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:CHAPTERS RCFEFACILITY NUMBER:
306004811
ADMINISTRATOR/
DIRECTOR:		RAMIREZ-RADABAUGH, RENEEFACILITY TYPE:
740
ADDRESS:24221 CHRISANTA DRIVETELEPHONE:
(949) 647-9240
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 4DATE:
06/10/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Joshua Radabaugh- AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual evaluation using the CARE Inspection Tool. LPA was greeted and granted entry by Administrator Joshua Radabaugh after stating the reason for the visit. Administrator Joshua Radabaugh has a certificate which expired April 5, 2026. Administrator Renee J Ramirez-Radabauh's certificate expired August 2, 2023. Both administrators do not have a current certificate at this time.

The following was observed during the inspection: The facility is located in a residential neighborhood comprised of four single or private resident bedrooms and two resident bathrooms. LPA observed four residents in care, one of which is on hospice. LPA observed a staff who was working alongside Admin Joshua on duty. Facility is operating within the conditions and limitations specified on the license.

LPA toured the physical plant. LPA inspected all common areas, the attached two car garage, all bedrooms, and the loft on the second floor. The resident bedrooms' were appropriately furnished, beds and bedding supplies were in good condition, adequate lighting was provided, and sufficient storage space for each residents' personal belongings were observed. Facility appeared clean, sanitary, and in good repair as well as all bathrooms. Slip resistant mats were observed to be available in the bathrooms. The hot water temperature in the resident bathrooms were within range measuring at 109.0 and 108.8 degrees Fahrenheit. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed sufficient two-day supply of perishables and seven-day supply of non-perishable food. LPA toured the exterior portion of the facility. The outdoor passageway is free of obstruction, and there is sufficient seating and shading. LPA observed one exit gate on the side of the property that was secured.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/10/2026 05:46 PM - It Cannot Be Edited


Created By: Jessica Cho On 06/10/2026 at 05:03 PM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CHAPTERS RCFE
FACILITY NUMBER: 306004811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interviews, Licensee Renee did not comply with the section cited above as 2 CEUs were missing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/02/2026
Plan of Correction
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Admin Joshua stated that Admin Renee will forward proof of the 2 hour of completed coursework to LPA via email on or before the POC due date.
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above delaying today's and previous visits which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2026
Plan of Correction
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Admin Joshua stated that all missing records will be completed and maintained on file 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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Jessica Cho
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/10/2026 05:46 PM - It Cannot Be Edited


Created By: Jessica Cho On 06/10/2026 at 05:03 PM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CHAPTERS RCFE
FACILITY NUMBER: 306004811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in four of four resident files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2026
Plan of Correction
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Administrator Joshua stated that the needs and services plan (or reappraisals) will be completed and maintained on file by POC due date.
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and per the last Technical Violation issued on the last annual visit on 9/17/25, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2026
Plan of Correction
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Administrator Joshua stated that the emergency disaster plan will be completed and maintained on file 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.
Lourdes Montoya
NAME OF LICENSING PROGRAM MANAGER:
Jessica Cho
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2026


LIC809 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CHAPTERS RCFE
FACILITY NUMBER: 306004811
VISIT DATE: 06/10/2026
NARRATIVE
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 The first aid kit contains all necessary elements. The fire extinguishers were expired last purchased on June 27, 2025. New fire extinguishers were purchased on today's date. The auditory devices and dual/functioning smoke/carbon monoxide detectors were tested and operational. Facility maintains emergency food and water. A working telephone number (949) 328-9627 was tested and remains available. Complaint Poster, 'See Something, Say Something,' (PUB 475) was available and posted in the correct size in the entry way.

LPA reviewed four residents and one personnel file. There is no documentation for the 20 hour training received for S1. Staff #1 (S1) indicated completing 2 hours of training this year. Present staff are background cleared and associated to the facility. The written Emergency Disaster Plan (LIC610E) was not completed after the last annual inspection conducted on September 17, 2025. The Emergency Preparedness Guide did not provide the same content. There was no documentation to verify that disaster drills were conducted quarterly. The last date on file was July 11, 2025.

LPA provided consultation on the following areas: to maintain all files and records required by the Department to prevent future delays in review, to complete the LIC610E, to ensure S1 meets their annual 20 hour training, to ensure all residents have a current care plan on file or updated as needed based on the change of condition, to ensure the Administrator's certificate is renewed timely, and to ensure the fire extinguishers are either serviced or purchased annually.

Based on the observations made during today's visit, deficiencies are being cited, and Technical Violations are being issued.

An exit interview was conducted with Administrator Joshua Radabaugh, and a copy of this report including the appeal rights were provided at exit.
NAME OF LICENSING PROGRAM MANAGER: Lourdes Montoya
NAME OF LICENSING PROGRAM ANALYST: Jessica Cho
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2026
LIC809 (FAS) - (06/04)
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