<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001339
Report Date: 06/20/2022
Date Signed: 06/20/2022 02:20:17 PM


Document Has Been Signed on 06/20/2022 02:20 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
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: 3DATE:
06/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Danilo Garcia, Davina Alipio, and David AlipioTIME COMPLETED:
10:50 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
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 Danilo Garcia and explained the reason for the visit. Administrators David Alipio and Davina Alipio arrived during the visit. Administrator David Alipio has an administrator certificate dated 07/05/2023

At 9:15 AM, LPA toured the facility with Administrator Davina Alipio. David Alipio joined the tour in progress. Facility has 2 residents present during today's visit. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. LPA spoke with both residents present during the visit. Facility appears clean and sanitary. All resident's rooms had the required elements as well as restrooms stocked with soap/ sanitizer and paper towels. LPA observed the screening/ sanitizing station in the entrance of the facility. Facility takes resident and staff temperatures daily and documents. Facility has covid precaution postings as well as required department postings. The facility mitigation plan has been completed and approved. LPA observed adequate emergency food as well as the first aid kit which contained all required items. LPA observed the posted emergency disaster plan. Smoke detectors are connected and tested operational during today's visit. Fire extinguisher is mounted and charged. LPA toured the outside grounds and observed ample shaded outside visitation area. Residents participate in activities such as walking, art, and BBQ's. 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 an ample emergency water supply at all times as well as current department visitor policies.

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: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
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 1