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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001339
Report Date: 07/05/2024
Date Signed: 07/08/2024 09:13:43 AM


Document Has Been Signed on 07/08/2024 09:13 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
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:
07/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:15 AM
MET WITH:Henry BatesTIME COMPLETED:
11:00 AM
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Licensing program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to conduct the annual required visit. LPA was greeted and granted entry into the facility by and explained the reason for the visit. Facility is licensed for 6 non-ambulatory clients with hospice waiver for 1. The facility currently has 3 clients with no clients on hospice. Michael Rillera has an Administrator Certificate expiring on 01/30/2026. Administrator Armando Flores arrived during the visit. The facility appears clean and sanitary.
LPA Lyman along with Licensee Michael Rillera toured the facility at 7:45 AM. LPA toured the physical plant, checked food service, and reviewed facility documentation. The home consists of four client bedrooms, two shared hall bathrooms, client restroom, one staff room, living room, dining room, and kitchen. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, and shower was free of mold/mildew. Water temperature measured between 109.2 and 116.1 degrees F in facility bathrooms. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including thermometer and scissors as well as a first aid manual. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. smoke detectors and carbon Monoxide detectors are hardwired and tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample shaded seating for clients. Exit gate is unlocked and operational. LPA observed ample emergency food and water supply. LPA reviewed the emergency disaster plan as well as infection control plan during the visit. Plans are thorough and complete. Facility provided documentation of last fire drill conducted on 04/09/2024 and drills are conducted quarterly. Facility provides activities in the form of games, exercise and outings in the community. At 9:00 AM, LPA reviewed three client files and two staff files. Client files contained required documents including admission agreements, physician reports and client appraisals. Staff files reviewed contained required documentation of training and criminal record clearance.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2024
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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