Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005256
Report Date: 07/02/2019
Date Signed: 07/02/2019 04:09:18 PM

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 VILLAFACILITY NUMBER:
306005256
ADMINISTRATOR:ALIPIO JR, IRENEO DFACILITY TYPE:
740
ADDRESS:5591 NORMA DRIVETELEPHONE:
(714) 606-1087
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY:4CENSUS: 4DATE:
07/02/2019
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:David and Divina Alipio, AdministratorTIME COMPLETED:
04:15 PM
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On 6/25/2019 @ 11:30 AM, Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility for the purpose of an annual evaluation. LPA rang the doorbell several times but no one answered. LPA could not hear any noise or movement coming from inside the facility. LPA peered into an open window near the front porch but was unable to see anyone. LPA departed the facility at 11:45 AM.
On 7/2/2109, LPA Tricia Danielson arrived unannounced to the facility to conduct an annual required evaluation. LPAs were greeted and granted entry to the facility by Caregiver Richard Gapuz. Administrators (ADs) David and Divina Alipio was notified of LPA's presence in the facility. ADs arrived shortly thereafter. LPA Danielson informed ADs of the purpose of the visit. Present in the facility at the time of the visit were two (2) staff and four (4) residents. At 2:15 PM, LPA requested and began reviewing four (4) resident records as well as two (2) staff files. LPA reviewed PNI with ADs as well with no concerns noted. LPA confirmed AD has a valid Administrator's Certificate which expires 7/05/2019. AD stated he has completed his recertification and is awaiting the arrival of his new certificate.
At 3:30 PM, LPA toured the facility interior and exterior with AD David. The required two (2) day perishable and seven (7) day non-perishable food supply was observed. Toxic substances, knives and other dangerous items were locked and inaccessible to residents. LPA observed the stove and refrigerator to be operational and maintained with cleanliness. Three (3) resident bathrooms were observed to have working sinks, faucets and flushing toilets. LPA tested hot water temperatures in resident bathrooms which ranged between 109.8 degrees and 119.8 degrees Fahrenheit. Grab bars and non-skid mats were also observed in resident bathrooms. Personal hygiene items for resident use were observed in each bathroom and were maintained free of commingling. LPA observed all resident rooms to have required linens, furnishings, adequate lighting as well as an operational smoke alarm. All linens and furnishings were clean and in good repair. Additional linens, towels, and washcloths were observed in the hallway cabinet. Smoke alarms and carbon monoxide detectors were tested and found to be operational during time of visit. LPA observed first aid kit in the office . Medications (CONTINUED ON LIC 809 C)
SUPERVISOR'S NAME: Lori BertrandTELEPHONE: (714) 703-2850
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (626) 423-4825
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2019
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: HEARTWELL CARE VILLA
FACILITY NUMBER: 306005256
VISIT DATE: 07/02/2019
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(CONTINUED LIC 809)
were inaccessible to residents, centrally stored and maintained in compliance. LPA observed required 72 hour emergency supplies in the garage. All pathways, doorways, and emergency exits were observed to be free of obstruction. Operational self-latching gates were observed on each side of the facility. There were no bodies of water observed anywhere on the property. Flashlights for use in the event of an emergency were observed in the resident rooms and found to be operational. LPA observed a facility phone and it was verified to be operational utilizing LPA cellphone. Regulatory required postings were observed in the living room. Facility was operating within the allowed capacity. Fire extinguisher was charged, mounted in kitchen and last serviced 7/23/2018. Last fire drill was conducted on 5/15/2019. LPA verified that fire/disaster drills are conducted at least quarterly. Emergency exit plan was posted and available for reference throughout the facility. An adequate number of staff were available during time of visit.
In order to update Community Care Licensing file, please provide updated copies of the following documents to CCLD by 7/26/2019:
1.) Designation of Administrative Responsibility (LIC308)
2.) Personnel Report (LIC500)
3.) Emergency Disaster Plan (LIC610E)
4.) Current Liability Insurance.

Based on the observations made during today’s visit, there were no deficiencies cited per Title 22, Division 6, of the California Code or Regulations. An exit interview to review this report was conducted with AD and a copy was provided.

SUPERVISOR'S NAME: Lori BertrandTELEPHONE: (714) 703-2850
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (626) 423-4825
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2019
LIC809 (FAS) - (06/04)
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