306005256-6-20-2024-22-AS-MTEA-D6EQDJ-20240620120450

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005256
Report Date: 06/20/2024
Date Signed: 06/20/2024 12:05:03 PM

Document Has Been Signed on 06/20/2024 12:05 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:	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: 4	DATE:	06/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Davidson Alipio		TIME COMPLETED:	12:15 PM

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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At around 8:30 AM, LPA Tea was greeted and granted entry into the facility by house manager, Ryan Tanisita and explained the reason for the visit. The Administrator, David Alipio arrived shortly after to assist during the visit. Facility is licensed for 4 non-ambulatory residents.

Currently there are four residents living at the facility.

At 8:37 AM, LPA Tea reviewed four resident files and two staff files. Residents files and staff files contained all required documentation. P&I Funds were reviewed and there were no discrepancies.

LPA Tea along with the Administrator toured the facility at 9:44 AM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of 4 resident bedrooms, staff area, 3 full bathrooms, living room, dining room, kitchen and garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and showers were free of mold/mildew. Water temperature measured between 108.8 F degrees and 104.3 F degrees. Water temperature is inconsistent, administrator will replace the current water boiler with a new one. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen drawer. LPA also observed toxin substances to be secured and locked and inaccessible to clients in the kitchen and garage. Fire extinguisher is fully charged. The facility’s last fire drill was conducted on April 01, 2024. Kitchen appliances are operational during today's visit.

Continuation on LIC809-C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

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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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: HEARTWELL CARE VILLA	FACILITY NUMBER: 306005256
	VISIT DATE: 06/20/2024

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LPA toured the outside grounds and there is ample seating with shade. There are two exit gates, one on each side of the house, they are self-latching and operational. LPA observed water supply and PPE equipment in the garage. Emergency food supply was observed in the staff area. For activities residents do puzzles and arts and crafts. The staff takes residents for walks and outings such as having picnics at the park and going shopping.

At 10:13 AM LPA reviewed medication storage and administration. Medications are stored in a locked cabinet in the staff area. Medications are being administered per physician order. LPA interviewed clients regarding their quality of care and spoke to staff present regarding care provided.

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

This report was reviewed with administrator, David Alipio and a copy of this report LIC809, 809-C, LIC858, LIC859, was read and provided to the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael Tea	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

LIC809 (FAS) - (06/04)

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