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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204954
Report Date: 05/31/2024
Date Signed: 05/31/2024 10:49:21 AM


Document Has Been Signed on 05/31/2024 10:49 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



FACILITY NAME:ELEGANT CARE VILLA D-1FACILITY NUMBER:
198204954
ADMINISTRATOR:LODERVINE ALIPIOFACILITY TYPE:
740
ADDRESS:2741 N. BELLFLOWER BLVD.TELEPHONE:
(714) 273-7676
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY:6CENSUS: 4DATE:
05/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Director LODERVINE ALIPIOTIME COMPLETED:
11:00 AM
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On 05/31/24 Licensing Program Analyst (LPA) Lizeth Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Director Lodervine Alipio as the purpose of the visit was explained. The facility is licensed to operate for (4) non-ambulatory and (2) ambulatory elderly adults ages 60 and above. The facility is approved for (1) hospice client, there are currently no hospice clients at the facility. Current facility census is 4, clients are Harbor Regional and South-Central Regional consumers. Facility fees are current, liability insurance is active with expiration date of 07/01/24.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (4) clients' rooms, (3) bathrooms of which (2) are private and (1) is shared, a living area with a work space for staff, a dining area, a kitchen, a laundry area, an outside seating area, and a garage that houses emergency supplies and an additional freezer. Client bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to clients. The water temperature properly measured between 105-120 F.. A supply of perishable and non-perishable food was observed, toxins and knifes were stored and inaccessible to clients, no weapons nor bodies of water on the premises, exits and walkways are free of debris/hazards.

LPA conducted a records review of 2 staff records, 2 client records, and 2 medication administration records, no discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The last drill was conducted on 03/23/24, 1 fire extinguisher fully charged, carbon monoxide and smoke detectors are interconnected and operational, land line observed.

Exit interview conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024
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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