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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003059
Report Date: 03/14/2024
Date Signed: 03/15/2024 11:13:21 AM


Document Has Been Signed on 03/15/2024 11:13 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 VILLA IIIFACILITY NUMBER:
306003059
ADMINISTRATOR:MYRNA ALIPIOFACILITY TYPE:
740
ADDRESS:1640 MELISSA WAYTELEPHONE:
(714) 776-2092
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY:6CENSUS: 6DATE:
03/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Estela De Venecia, Caregiver and David Alipio, Assistant AdministratorTIME COMPLETED:
12:17 PM
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 On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required Annual inspection. LPA was greeted and granted entry into the facility by Caregiver 1 (CG1). LPA Quiroz called Administrator Assistant (AAD) David Alipio and explained the nature of the visit. (AAD) David Alipio arrived during today's visit.
This is a Residential Care Facility for the Elderly level 4-I home approved for six (6) Non-Ambulatory Residents of which 1 (one) may be bedridden and has a hospice waiver for two (2) residents. There are six (6) residents in care of which zero (0) are receiving hospice care services. There are no active COVID-19 cases in the facility at this time. The Facility Administrator Davina Alipio has an Administrator Certificate with expiration date of 6/19/2024.
LPA Quiroz along with (CG1) toured the interior and exterior of the facility. During today's inspection tour, LPA Quiroz observed three residents in the living-room area watching television with staff supervision, two residents in their bedroom resting. Facility staff indicated Resident 1 is currently at the hospital-Pending discharge. LPA Quiroz interacted and interviewed with staff and residents during today's visit.
LPA Quiroz inspected resident's bedrooms and bathrooms. The water temperatures were recorded to be between 118.0-119.0 degrees Fahrenheit. LPA Quiroz inspected resident’s bedrooms and appeared to be clean. Facility temperature in resident's bedrooms and throughout the facility was recorded to be within normal limits. LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food, water and PPE in garage area readily available for staff and residents. Functional and operational washer and dryer observed in garage area. LPA Quiroz toured the outside of the facility and observed seating and shaded area in the backyard for residents and visitor's enjoyment.
During today's visit, LPA Quiroz provided Consultation on Title 22 and Infection control. An exit interview was conducted with (AAD) David Alipio and a copy of this report, LIC 858, LIC 811- Confidential names, were provided at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
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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