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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004491
Report Date: 02/27/2025
Date Signed: 02/27/2025 12:01:28 PM

Document Has Been Signed on 02/27/2025 12:01 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ELEGANT CARE VILLA - BUENA PARKFACILITY NUMBER:
306004491
ADMINISTRATOR/
DIRECTOR:		MARK JOHN M. ALIPIOFACILITY TYPE:
740
ADDRESS:5491 BURLINGAME AVENUETELEPHONE:
(714) 606-1087
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
02/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Karen SantosTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On February 27th, 2025 Licensing Program Analyst (LPA) William Vanegas made an unannounced inspection for the purposes of an annual inspection. Upon arrival LPA Vanegas was greeted and granted entry by Care Giver (CG) Karen Santos and expalined the purpose of the visit. LPA Vanegas began a tour of the facility and observed the following.

This is a one storied home with four bedrooms, and two bathrooms. There is also an attached two car garage. LPA Vanegas observed the kitchen area to be clean and free of any mildew or debris. LPA Vanegas observed there to be a two-day supply of perishable food and a seven day supply of non-perishable food. LPA Vanegas observed there to be a sufficient amount of emergency water.

LPA Vanegas observed restrooms to be clean and free of mildew and debris. Water faucets and toilets tested to be operational. LPA Vanegas observed bathrooms to have all required furnishing such as grab bars, shower chair, and slip resistant floor matts. Water tested between 112.2 and 112.6 degrees.

LPA Vanegas observed resident bedrooms to have all required furnishings such as a lamp, chest drawers, enough closet space, a bed, and clean linens in good repair; meaning no strains or tears. Rooms are big enough to lounge freely and not have any obstructions blocking entry ways.

LPA Vanegas observed fire extinguishers to be up to date, and fully charged. LPA Vanegas observed all smoke and carbon monoxide detectors to be in good repair, and all tested operational. LPA Vanegas observed first aid kit to have all required equipment such as adhesive tape, scissors, tweezers, a thermometer, and bandages.

CONTINUED ON LIC809C
Armando J LuceroTELEPHONE: (714) 703-2866
William VanegasTELEPHONE: (714) 497-7621
DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2025
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ELEGANT CARE VILLA - BUENA PARK
FACILITY NUMBER: 306004491
VISIT DATE: 02/27/2025
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LPA Vanegas observed the outside of the facility to be clean and in good repair. LPA Vanegas observed backyard to be big enough to participate in outdoor activities upon resident request and an outdoor shaded sitting area. LPA Vanegas observed back yard exit routes to be free of any obstructions and side doors to be self latching and unlocked.

LPA Vanegas reviewed emergency disaster plan and infection control plan to be up to date, and to be filled out correctly; containing all required components. LPA Vanegas reviewed six resident files, and five staff files. All files (Staff and Resident) contained all required documentation, and all staff training was up to date and documented correctly.

LPA Vanegas reviewed P&I with Administrator (AD) Divina Alipio and all balances were accounted for and documented correctly. LPA Vanegas reviewed medications with AD, and all medications are being documented correctly. Per LPA Vanegas review medications are being administered per physicians orders.

Based on observations made during today's visit no deficiencies will be cited per title 22 Chapter six of the California Code of Regulations. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2866
LICENSING EVALUATOR NAME: William VanegasTELEPHONE: (714) 497-7621
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
LIC809 (FAS) - (06/04)
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