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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004425
Report Date: 03/08/2023
Date Signed: 04/04/2023 02:23:49 PM

Document Has Been Signed on 04/04/2023 02:23 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
EL SEGUNDO, 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:
03/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Davidson Alipio, Joy Alipi,TIME COMPLETED:
05:10 PM
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On 03/08/23, Licensing Program Analysts (LPA’s) Lizeth Villegas, Felisa Shirley and LPM Janae Hammon conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met by Administrator
Davidson & Joy Alipio to explain the purpose of today’s visit. The facility is licensed to operate for 3 non-ambulatory developmentally ill disabled adults with restricted health conditions.

The facility is a single story 3 bedrooms, 1 private restroom, 1 common restrooms, laundry room area, dining area, kitchen, pantry, linen closet, 1 staff office area, a designated outdoor shaded area and a detached garage. The facility has a working landline, 1 phone in the dinning area, 1 phone in the kitchen and 1 phone in the staff office area. Fire extinguishers were charged, smoke detectors and carbon monoxide were operable. A review of Fire Drills was observed to be maintained in order and accurate, the last fire drill and disaster drill were on 01/10/2023.

LPA toured the physical plant and there were no bodies of water or obstructions on the premises.Resident rooms were inspected, beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked during the visit. All bathrooms were found to be within Title 22 regulations and were clean and operational. The facility water temperatures measured over 126 to 133 degrees F. which is not incompliance to title 22 regulations
LPA observed the facility to be sanitary and appropriately furnished at the time of visit. All storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. LPA reviewed Medication Administration Records (MAR) revealed to be accurate and maintained in order. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately

Deficiencies cited under California code of regulations title 22 division 6, chapter 1

An exit interview was conducted, appeals rights explained, and a copy of this report was provided to Joy Alipio
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2023
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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Document Has Been Signed on 04/04/2023 02:23 PM - It Cannot Be Edited


Created By: Lizeth Villegas On 03/08/2023 at 04:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ELEGANT CARE VILLA D-II
FACILITY NUMBER: 306004425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)


Furniture, fixtures, equipment and supplies (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water.

(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above as kitchen sink has water measuring at 133 F and bathroom #1 water measured 128 and bathroom #2 measured at 126 F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/09/2023
Plan of Correction
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Administrator will monitor water temp to ensure all faucets are withing 105 to 120 F and submit proof to LPA by POC due date 3/9/23
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023


LIC809 (FAS) - (06/04)
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