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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001339
Report Date: 07/12/2021
Date Signed: 07/12/2021 03:54:44 PM

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:ELEGANT CARE VILLAFACILITY NUMBER:
306001339
ADMINISTRATOR:DAVIDSON ALIPIOFACILITY TYPE:
740
ADDRESS:12712 ADAMS STREETTELEPHONE:
(714) 901-1274
CITY:GARDEN GROVESTATE: CAZIP CODE:
92845
CAPACITY:6CENSUS: 2DATE:
07/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Danny Garcia and David AlipioTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Danny Garcia and explained the reason for the visit. Licensee Myrna Alipio and Administrators David Alipio and Davina Alipio arrived during the visit.

At 1:45 PM, LPA toured the facility with Administrator David Alipio. Facility has 2 residents during today's visit. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All residents rooms had the required elements as well as restrooms stocked with soap/ sanitizer. LPA observed the screening/ sanitizing station in the entrance of the facility. Facility takes resident temperatures daily and documents. Facility has covid precaution postings as well as all required department postings. Davina Alipio has an administrator certificate expiring on 06/19/2022. The facility mitigation plan has been completed and approved. LPA observed adequate emergency food and water as well as the first aid kit. LPA toured the outside grounds and observed ample shaded outside visitation area. Exit gate is unlocked and self latching. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. All staff and residents are vaccinated for Covid-19. LPA reviewed all resident files which contained all required documentation including updated emergency information.

LPA consulted with Administrator Alipio regarding the importance of maintaining a ample emergency water at all times. Administrator to post the "Let us No" poster in the entrance of the facility.

No citations noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2021
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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