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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004425
Report Date: 03/14/2024
Date Signed: 03/14/2024 02:09:35 PM

Document Has Been Signed on 03/14/2024 02:09 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:ELEGANT CARE VILLA D-IIFACILITY NUMBER:
306004425
ADMINISTRATOR:IRENEO D, ALIPIO, JR.FACILITY TYPE:
735
ADDRESS:3723 MCNAB AVENUETELEPHONE:
5624292328
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY: 3CENSUS: 3DATE:
03/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Joy Alipio, AdministratorTIME COMPLETED:
02:27 PM
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On 03/14/23, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit using the CARE Inspection Tool. LPA was met by Administrator, Joy Alipio, to explain the purpose of today’s visit. The facility is licensed to operate for three (3), non-ambulatory, developmentally disabled adults with restricted health conditions.
The facility is a single-story house located in a residential neighborhood with 3 client bedrooms, 1 private restroom to be used by one client, 1 common restroom, laundry/pantry room area, dining area, kitchen, linen closet, 1 staff office area, a designated outdoor shaded area and a detached garage. The facility has a working land line with 1 phone in the dining area, 1 phone in the kitchen area and 2 phones in the staff office area. One (1) fire extinguisher was fully charged as of July 17, 23. Five (5) smoke detectors and one (1) carbon monoxide were fully operable. A review of Fire Drill(s) was observed to be maintained in order and accurate, the last fire drill was conducted on 03/02/24 and the last disaster drills were conducted on 01/08/24 and 02/09/24.
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 between 112.6 and 113.9 degrees F.
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 were stored and not accessible to residents. LPA reviewed Medication Administration Records (MAR) which revealed to be accurate and maintained in proper order. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately, displaying proper dating methods.
No Deficiencies were cited during today's visit. Technical Assistance Advisory Notes were provided, see LIC9102TV AND LIC9102TA.
An exit interview was conducted and a copy of this report was provided to Administrator, Joy Alipio.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
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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