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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005516
Report Date: 12/06/2021
Date Signed: 12/06/2021 02:49:02 PM

Document Has Been Signed on 12/06/2021 02:49 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:ST. IRENEUS CARE VILLAFACILITY NUMBER:
306005516
ADMINISTRATOR:ALIPIO JR, IRENEO DFACILITY TYPE:
735
ADDRESS:10030 HOLDER STTELEPHONE:
(714) 699-1327
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 4CENSUS: 3DATE:
12/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:House Manager, Richard Gapuz TIME COMPLETED:
03:00 PM
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On this day Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and was granted entry into the facility by House Manager. Upon entry LPA's temperature was checked and logged. LPA explained the reason for the visit.

During the visit Administrator David Alipio arrived. LPA toured the facility with Administrator and House Manager , Facility is a 4 bedroom and 4 bathroom single story home. There are 3 Clients in care. LPA observed facility has required Department postings. LPA toured all clients rooms, all rooms where within regulations. All restrooms observed contained working water basin, soap, toilet paper and hand towels. Clients were observed relaxing in bedrooms.

Facility has PPE supply. Facility has 2 refrigerators and pantry's with ample food supply. LPA observed facility has emergency food and water supply. Facility has 1 fire extinguisher which is fully charged. Facility has evacuation plan posted. Facility has a secured location for Client medication and files. Facility has 30 days supply of medications for clients. LPA reviewed Clients files during visit. Clients emergency contact information and physicians reports are current. Facility has designated visitation area.

An exit interview was conducted with House Manager Richard Gapuz and copy of report was left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2021
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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