Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001339
Report Date: 01/24/2017
Date Signed: 02/01/2017 01:52:14 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:IRENEO D. ALIPIO,JR.FACILITY TYPE:
740
ADDRESS:12712 ADAMS STREETTELEPHONE:
(714) 901-1274
CITY:GARDEN GROVESTATE: CAZIP CODE:
92845
CAPACITY:6CENSUS: 6DATE:
01/24/2017
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
08:32 AM
MET WITH:Adminstrator Divina AlipioTIME COMPLETED:
11:01 AM
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Licensing Program Analyst (LPA) Shobhana Frank made an unannounced visit to the facility for the purpose of conducting an Required - 3 Year inspection evaluation. LPA met with ASIS/Administrators Divina Alipio and Susana Mayuga. ASIS/Administrator Susana Mayuga accompanied LPA on the inspection of the physical plant's interior and exterior.

LPA observed the facility to be neat, clean, organized and well maintained. No health/safety hazards were observed during the inspection. The Licensee continues to operate the facility within the terms, conditions and limitations specified on the license. Currently one resident is in care. The resident present at the facility during the time of the inspection. LPA observed a two day supply of perishable and a seven day supply of non-perishable foods available. Smoke detectors were tested and found operational; the hot water temperatures measured at 118.3 degrees F. Auditory devices were tested on all exits and fond to be operational. LPA confirmed that the administrator has a current administrator certificate.
LPA conducted review of resident and staff files. LPA observed centrally stored medication Locked in cabinet by the living room. LPA reviewed resident’s medication records and Hospice Care file. All reviewed files are complete.

Based on the observations made during today’s visit, No deficiencies were observed or cited per California Codes of Regulations, Title 22, and Chapter 8:

Exit interview was held. A copy this report was provided to the representative.

SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana FrankTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2017
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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