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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001339
Report Date: 07/05/2024
Date Signed: 07/11/2024 08:44:54 AM


Document Has Been Signed on 07/11/2024 08:44 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:David Alipio and Noeme GolfoTIME 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 and explained the reason for the visit. Facility is licensed for 6 non-ambulatory clients with 1 hospice waiver. The facility currently has 3 clients with none on hospice. Myrna Alipio has an Administrator Certificate expiring on 07/14/2025. Administrator David Alipio arrived during the visit. The facility appears clean and sanitary.
LPA Lyman along with Administrator David Alipio toured the facility at 7:58 AM. LPA toured the physical plant, checked food service, and reviewed facility documentation. The home consists of three client bedrooms, one shared hall bathroom, client restroom, staff office, 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 113.7 and 114.2 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, tweezers and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke detectors and Carbon Monoxide detectors tested operational during today's visit. Fire extinguishers is fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating for clients. Exit gate is unlocked, self latching and operational. LPA observed ample emergency food and water supply as well as emergency packs for clients. 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 06/12/2024 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 four staff files. Client files contained required documents including admission agreements, physician reports and client appraisals. CONTINUED ON LIC 809C DATED 07/05/2024
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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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: 07/05/2024
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Staff files reviewed contained required documentation of training, health screens/ TB and criminal record clearance. Staff files reviewed contained CPR certification. At 9:45 AM, LPA reviewed medication storage and administration. Facility uses a medication administration record. Medications are stored in a locked cabinet and are being administered per physician order. LPA reviewed P & I money with staff. Ledgers match cash on hand.



Based on the observations made during today’s visit, NO deficiencies are being cited. This report was discussed with the facility representative and a copy was provided.
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
LIC809 (FAS) - (06/04)
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