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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004425
Report Date: 03/16/2022
Date Signed: 03/16/2022 03:55:30 PM

Document Has Been Signed on 03/16/2022 03:55 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ELEGANT CARE VILLA D-IIFACILITY NUMBER:
306004425
ADMINISTRATOR:IRENEO D, ALIPIO, JR.FACILITY TYPE:
735
ADDRESS:3723 MCNAB AVENUETELEPHONE:
(562) 429-2328
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY: 3CENSUS: 3DATE:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Joy Alipio TIME COMPLETED:
04:00 PM
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On 03/16/22 Licensing Program Analyst (LPA) Jade Jordan conducted an Unannounced visit to conduct an Annual inspection with an emphasis on infection control. LPA was met by Administrators Divina Alipio, and Joy Alipio.

Upon entry LPA was screened for Covid-19 Symptoms, and temperature was manually taken.

The facility is family home, located on a residential street. The facility is licensed for (3) non ambulatory developmentally disabled adults. All clients are Harbor Regional Center clients.

The facility interior includes (3) client bedrooms, (2) bathrooms, living room/activity room, dining area, kitchen with washer and dryer and a detached garage used for storage. All bedrooms had the required furnishings, including 1 Bed with fitted sheet, flat sheet, comforter, 1 Chair, adequate lighting, dresser/drawer space and closet. All bathrooms are sanitary, free of mold/mildew with working toilets, faucets, and showers. Hot water measured at 116. degree's. Hallways, and walk ways are free of obstruction and debris.

The outside Patio has a shaded area, with tables and chairs. The landscape was in neat condition.

Several Active Administrators certificates were observed and posted on the wall as well as other required
postings. Administrator certificate expires on 01/02/23.

LPA observed an ample supply of Perishable/Non Perishable items.
Sharps, Toxins, and Medication were locked and inaccessible to clients in care.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2022
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ELEGANT CARE VILLA D-II
FACILITY NUMBER: 306004425
VISIT DATE: 03/16/2022
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LPA reviewed 2 staff files, 2 resident files, 1 Pni, and 1 Mars. All Records were up to date, and retained
the required documentation, including health screenings, personal rights, and Elder Abuse.

LPA observed a minimum of 30 day supply of PPE's. Observed were N95's , Surgical masks, Face shields,
Gowns, Trash Cans with lids, Hand Sanitizer, Soap, Paper Towels and disinfectant. The facility retains a minimum of 30 day supply of medications, and all emergency contact numbers are up to date.The facility has
Covid -19 positings throughout the facility, and encourages good hand washing hygiene. Facility staff sanitize 3x's a day.

A Technical Advisory was given for the following area(s):

N95 Fit testing


An exit interview was conducted, and a copy of this report was provided. No citations were
issued during this visit.



SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC809 (FAS) - (06/04)
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