306005256-6-27-2022-22-AS-RQUZ-CFSS5A-20220627133400

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005256
Report Date: 06/27/2022
Date Signed: 06/27/2022 01:34:05 PM

Document Has Been Signed on 06/27/2022 01:34 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:	HEARTWELL CARE VILLA		FACILITY NUMBER:	306005256
ADMINISTRATOR:	ALIPIO JR, IRENEO D		FACILITY TYPE:	740
ADDRESS:	5591 NORMA DRIVE		TELEPHONE:	(714) 606-1087
CITY:	WESTMINSTER	STATE: CA	ZIP CODE:	92683
CAPACITY:	4	CENSUS: 3	DATE:	06/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:02 PM
MET WITH:	Davidson Alipio, Administrator		TIME COMPLETED:	01:40 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

On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Quiroz was greeted and granted entry into the facility by Direct Support Professional (DSP) Ryan Tan. Administrator Davidson Alipio arrived shortly after. Facility indicated screening all incoming visitors prior to entering the facility. Facility is licensed to provide services to a capacity of four (4) developmentally disabled clients Ages 60 and over.

Administrator Davidson Alipio has a current Administrator certificate with expiration date of July 5, 2023.

On or about 12:25 pm, LPA Rosie Quiroz along with AD Alipio began the tour of the inside and outside of the facility. There are (3) three clients in care and there are no active COVID-19 cases in the facility. During today's facility inspection, LPA Quiroz observed three clients relaxing and resting in living room area with staff supervision. Facility consists of four private bedrooms, 3 bathrooms for staff and clients, one living room, office room with sitting area, 2 car garage, functional and operational washer and dryer in garage area, kitchen with dining area.

LPA Quiroz interacted with clients during today's visit. Clients present during today's visit appeared to be clean and well taken care of.

LPA Quiroz observed a COVID-19 check in station in the entry of the facility; LPA Quiroz observed required department COVID-19 precautionary postings in the facility as well as hand washing signs throughout the facility. Facility temperature recorded to be 73 degrees Fahrenheit.

CONTINUED ON NEXT PAGE...

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: HEARTWELL CARE VILLA	FACILITY NUMBER: 306005256
	VISIT DATE: 06/27/2022

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
26
27
28
29
30
31
32

All restrooms observed to have a supply of soap, appeared to be clean and water temperatures were recorded to be 105.0 degrees Fahrenheit. Clients bedrooms appeared to be clean. All bedrooms observed to have all required components. LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food, water and PPE in garage area and office area readily available for staff and clients. LPA Quiroz toured the outside of the facility and observed seating and shaded area for clients and visitors enjoyment in backyard area.

The facility has completed the LIC 808 Mitigation Plan. The LIC 808 plan was received by the Department on June 7, 2021. During today's visit, LPA Quiroz reviewed and approved LIC 808 Mitigation Plan dated June 7, 2021.

LPA Quiroz was informed that all clients and staff have had their COVID-19 vaccinations and first Booster. Facility indicated to be recording clients temperatures daily three time per day.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

During today's visit, LPA Quiroz provided Consultation on Title 22 and COVID-19 Infection control throughout today's visit.

This report was reviewed with Administrator Davidson Alipio, and a copy of this report and LIC 811 Confidential Names were provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2