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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005368
Report Date: 09/19/2022
Date Signed: 09/19/2022 12:03:37 PM

Document Has Been Signed on 09/19/2022 12:03 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:SANTA AVILA CARE VILLAFACILITY NUMBER:
306005368
ADMINISTRATOR:ALIPIO, DIVINA JOY M.FACILITY TYPE:
735
ADDRESS:5501 MEINHARDT RDTELEPHONE:
(657) 352-8841
CITY:WESTMINISTERSTATE: CAZIP CODE:
92683
CAPACITY: 4CENSUS: 4DATE:
09/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Divina Joy Alipio, AdministratorTIME COMPLETED:
12:15 PM
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On 09/19/2022 at 11:00am, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection focusing on Infection Control procedures. LPA was greeted and granted entry by caregiving staff and explained the purpose of the visit after being temperature checked. Administrator was notified by phone and arrived later to assist with the visit.

At approximately 11:30am, LPA accompanied by administrator toured the physical plant of the facility. There are currently four (4) clients in care, two (2) of which are attending day program remotely. Clients are observed relaxing in the facility's common area and front yard and appear clean and well taken care of. The four individual bedrooms include all necessary components. Bathrooms are equipped with grab bars and slip mats. Facility is clean, sanitary and free of odors in all areas inspected.

Sharp instruments are kept in a locked cabinet in the kitchen along with cleaning supplies. More cleaning supplies are secured in a hallway closet and in the bathrooms. The centrally stored medication is located in a locked filing cabinet. LPA observed a sufficient supply of food and water present. Emergency supplies, water and rations are also stored in the attached garage. The facility has an ample supply of linen available for use by clients.

LPA observed the facility has COVID-19 Precautions posters and all required department postings. Staff present is adequately cleared and associated in Guardian. The fire extinguisher present is charged and has up-to-date maintenance shown on the attached tag.

CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2022
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: SANTA AVILA CARE VILLA
FACILITY NUMBER: 306005368
VISIT DATE: 09/19/2022
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CONTINUED FROM LIC809

LPA and administrator toured the outside of the facility and observed it to be free of obstructions. Outdoor furniture and a shaded area are present in the front yard for the enjoyment of clients and visitors. The perimeter gate on the side of the facility is self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2022
LIC809 (FAS) - (06/04)
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