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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001339
Report Date: 07/24/2019
Date Signed: 07/24/2019 03:04:47 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: 3DATE:
07/24/2019
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:David Alipio- AdministratorTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Alisa Ortiz and Betty Smith made an unannounced visit on this day at 2:00 PM for the purpose of conducting an annual random inspection. LPA was greeted and allowed entry by staff. LPA was joined shortly after by designated back ups David Alipio.

LPA Ortiz began to review client files. LPA Ortiz observed three of three client files. LPA Ortiz observed the following but not limited to: physician report, individual program plan, admission agreement and TB test. LPA Smith reviewed 3 of 3 client Personal and Incidental (P&I) monies and observed P&I to match P&I log. Client medications were reviewed and found to be being given as prescribed. LPAs confirmed that a valid Administrators certificate is maintained on the premises. Administrators Certificate observed expires 7/2021.

LPAs reviewed 2 of 2 staff files. LPA reviewed a total of 2 staff files. LPA observed the following but not limited to: personnel record, criminal record statement, first aid, health screening & TB test.

During this time physical plant was inspected by LPA Betty Smith. LPA Smith observed the following but not limited to: Kitchen was inspected for proper sanitation and cleanliness. Food was found to meet minimum requirement of two days perishables and seven days non-perishables. Smoke alarms were tested and observed operational. Client bedrooms were found to have required furnishings. Hot water temperature in resident bathroom was observed to measure 114.5 degrees F. Hallways and exit ways were observed clear of debris and/or clutter. (continued...)
SUPERVISOR'S NAME: Lori BertrandTELEPHONE: (714) 703-2850
LICENSING EVALUATOR NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: ELEGANT CARE VILLA
FACILITY NUMBER: 306001339
VISIT DATE: 07/24/2019
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(continued...)

LPA Smith reviewed resident medications and observed the following: medications appeared to be being given as prescribed.

Facility appears to be operating in compliance of Title 22 Division 6.

An exit interview was conducted and a copy of this report and confidential names list was provided.
SUPERVISOR'S NAME: Lori BertrandTELEPHONE: (714) 703-2850
LICENSING EVALUATOR NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2