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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005368
Report Date: 10/02/2024
Date Signed: 10/02/2024 11:58:27 AM

Document Has Been Signed on 10/02/2024 11:58 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SANTA AVILA CARE VILLAFACILITY NUMBER:
306005368
ADMINISTRATOR/
DIRECTOR:		GOLFO, NEOMEFACILITY TYPE:
735
ADDRESS:5501 MEINHARDT RDTELEPHONE:
(657) 352-8841
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY: 4CENSUS: 4DATE:
10/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Neome GolfoTIME VISIT/
INSPECTION COMPLETED:
12:00 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. LPA Tea was greeted and granted entry into the facility by DSP Lead Staff, Leidenne Bueno. Administrators (AD) Neome Golfo and Divinajoy Alipio arrived shortly to assist with the visit. The facility is licensed for 4 ambulatory clients of which 2 maybe non-ambulatory. Currently there are 4 clients living here during today's visit.

At 8:39 AM, LPA Tea reviewed four client files and four staff files. Client files and staff files contained all required documentation. AD Golfo certificate expires on November 12, 2025 and AD Alipio expires on November 2, 2025.



LPA Tea along with the AD Alipio toured the facility at 9:45 AM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a one-story home with four client bedrooms and three bathrooms. The facility has a kitchen, dining room, living room, family room/office area and garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Water temperature measured between 105.8 F degrees and 111.9 F degrees. Client 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 bandages, 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 underneath the kitchen sink, separately from toxins. LPA also observed toxin substances to be secured and locked underneath the kitchen as well and stored in a locked storage closet by the front entry way. (Annual continued on LIC809C)
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2024
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: SANTA AVILA CARE VILLA
FACILITY NUMBER: 306005368
VISIT DATE: 10/02/2024
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Fire extinguisher in the kitchen is fully charged and last service on July 12, 2024. The facility’s last disaster drill was conducted on October 1, 2024. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating with shade in the front. There is one self-latching gate on the right side of the facility. LPA observed emergency supplies, food, and water in the garage. LPA Tea observed clients leaving for their doctor appointment and coming back to the facility and relaxing outside in the front yard. The staff provide activities based on client’s personal preference such as puzzles, coloring, exercises, Zumba, and watch TV. The staff also takes the clients out for community outings.

LPA reviewed medication storage and administration. Medications are stored in a locked cabinet in the dining room area. Medications are being administered per physician order. P&I Funds were checked and meet department standards. 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 administrators Neome Golfo and Divinajoy Alipio and a copy of this report LIC809, 809-C, LIC858, LIC859, and was read and provided to the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC809 (FAS) - (06/04)
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