306004491-4-8-2022-22-AS-ETAA-CDB3KZ-20220408181957

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004491
Report Date: 04/08/2022
Date Signed: 04/08/2022 06:20:58 PM

Document Has Been Signed on 04/08/2022 06:20 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ELEGANT CARE VILLA - BUENA PARK		FACILITY NUMBER:	306004491
ADMINISTRATOR:	MARK JOHN M. ALIPIO		FACILITY TYPE:	740
ADDRESS:	5491 BURLINGAME AVENUE		TELEPHONE:	(714) 606-1087
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90621
CAPACITY:	6	CENSUS: 5	DATE:	04/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Susana Garcia, Divina Alipio		TIME COMPLETED:	06:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs ) Edward Tapia, Jessica Cho, Celine De Perio and Licensing Program Manager (LPM) Sheila Santos made an unannounced required annual inspection in this facility. LPAs met with lead staff Susana Garcia and stated the purpose of this visit. AD Divina Alipio arrived during the visit at 4:20pm and provided assistance. The facility is a single level structure and licensed for six non-ambulatory of which one is non-ambulatory and 4 ambulatory. This facility offers a Level IV- C&I service. About 3:20 PM, LPAs Tapia, Cho, De Perio and LPM Santos were granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPAs observed five clients in care and two staff members on duty. LPAs toured the interior and exterior portions of the facility at 3:45pm. There were four private client's rooms. Residents rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide, and auditory exit alarms were tested to be operational. Bathroom (1) was observed to be in good repair and provided with grab bars and hot water was measured at 110.4 degrees Fahrenheit. Bathroom( 2) was observed to be in good repair and provided with grab bars and hot water was measured at 110.1 degrees Fahrenheit. Bathrooms 1 and 2 were observed with exposed razors and staff immediately removed and locked the razors. Facility met the minimum two day supply of perishable and seven day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to clients in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguishers were observed. For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. Ladders and gardening tools were observed and removed so residents could not access them. Debris from back ally were cleared from obstructions. Laundry room was in good repair and first aid kits were removed and locked.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ELEGANT CARE VILLA - BUENA PARK	FACILITY NUMBER: 306004491
	VISIT DATE: 04/08/2022

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Kitchen was in good repair with knifes kept locked. LPA Tapia reviewed the COVID 19 mitigation plan of the facility. LPAs discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed. No citation was issued. An advisory was issued today.

LPA Tapia conducted an exit interview with Administrator Divina Alipio and copy of this report was explained and left in the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC809 (FAS) - (06/04)

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