306004491-3-22-2023-22-AS-LMAZ-CQ73H6-20230322181523

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004491
Report Date: 03/22/2023
Date Signed: 03/22/2023 06:16:18 PM

Document Has Been Signed on 03/22/2023 06:16 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: 6	DATE:	03/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Divina Alipio		TIME COMPLETED:	11:30 AM

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 (LPA ) Lydia Martinez made an unannounced Required - 1 Year inspection. LPA met with Lead Staff Susana Garcia and stated the purpose of this visit. Administrator (AD) Divina Alipio arrived shortly after and provided assistance. The facility is a single level 4-bedroom, 2 bathroom home with an attached garage. Facility is licensed for six non-ambulatory. This facility offers a Level IV service. LPA Martinez, along with Carestaff Garcia conducted walk through of inside and outside of the facility. LPA observed four clients in care and three staff members on duty. Two clients were at Program. There were four Client rooms to which two are double occupancy. Two Clients were watching TV in living room; two others were in their rooms. Clients appeared clean and happy. Client rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Facility has hourly staff - (no live-in). Smoke detectors are centrally wired, Carbon Monoxide, and Auditory Exit Alarms were tested and were operational. Bathrooms were observed to be in good repair and provided with grab bars, non-skid matt, paper towels and toilet paper. Hot water in Client's bathrooms was measured at 108.2 degrees F. Kitchen is in good repair with knives kept locked. 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 the Clients in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguishers were observed and charged. For the exterior portion, the facility had an outside covered patio with furniture and in good repair; and grounds were free of tripping hazards. Laundry room was in good repair and First Aid Kit observed contained all required items. P&I records; each client's balance matched with the ledger account and the funds were accurate. Facility conducted it's last emergency drill on 12/22/2022. (cont on LIC809C)

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

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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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: 03/22/2023

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Client Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medical and Dental - LPA reviewed 3 client files. LPA noted Admission Agreement, Medical Assessment and TB test results, Identification and Emergency information, Individual Program Plan, Consent forms, Centrally Stored Medication/Destruction Records, Safeguard for Personal Property/Valuables, and Personal Rights Notification.

Personnel Records/Training/and Staffing- 3 records were reviewed. LPA reviewed employee records for First Aid certification, Finger Print Clearance, Personnel/Job Application, Health Screening and TB test results, Criminal Record Statement, Employee Rights, Training Verification, and current Administrator Certification, which expires on 06/19/2024.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report will be sent to the email on file.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia Martinez	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC809 (FAS) - (06/04)

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