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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005368
Report Date: 10/12/2023
Date Signed: 10/12/2023 10:20:46 AM

Document Has Been Signed on 10/12/2023 10:20 AM - 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 ASC, 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:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY: 4CENSUS: 4DATE:
10/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:Divina Alipio - AdministratorTIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at Santa Avila Care Villa to conduct an unannounced Required 1 Year Inspection. LPA arrived at the facility at 8:40am, LPA was greeted and granted entry by Assistant Administrator (AAD) Neome Golfo. Administrator (AD) Divina Alipio joined the inspection at 9:30am.

The facility is a one-story home with four bedrooms, three bathrooms, living room, kitchen, dining room, sun room, backyard, front patio, and an attached two car garage. There is one exit gate on the side of the house. There is a shaded seating area on the front patio. LPA did not observe any hazards or obstacles in back yard. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. Toxic chemicals, cleaning solutions and disinfectants are inaccessible to clients and will be stored and locked under the sinks in the kitchen and bathrooms and in the garage. Medication is stored in a locked cabinet in the dining room. First Aid kit is mounted on the wall in the sun room. Files are in a closet in the sun room. LPA reviewed two out of four client files and medication. LPA reviewed three staff files. Clients were away at day program. The fire extinguisher is fully charged and was last serviced on 7/17/23. For activities, the facility has games, gardening, karaoke, exercises and outings. All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 115.5 degrees Fahrenheit in the bathroom in bedroom 3, 111 degrees Fahrenheit in the bathroom between the other two bathrooms and 110.6 degrees Fahrenheit in the bathroom near bedroom 4. A supply of extra linen, hygiene supplies and clothing is stored in the hallway cabinets. Emergency Phone Numbers, Exit Plan & Menu are posted and available for review. There is a 2-day supply of perishable food and 7-day supply of non-perishable food on hand. Smoke and carbon monoxide detector tested operational. Stove burners, oven, refrigerators, dishwasher, microwave, washer and dryer are operational.
Based on the observations made during today's visit, no deficiency is being cited as per Title 22 Division 6 Chapter 2 of the California Code of Regulations. An exit interview was conducted with Administrator Divina Alipio, and a copy of this report was provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2023
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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