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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005687
Report Date: 11/26/2024
Date Signed: 11/27/2024 09:03:57 AM

Document Has Been Signed on 11/27/2024 09:03 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 VERONICA CARE VILLAFACILITY NUMBER:
306005687
ADMINISTRATOR/
DIRECTOR:
ALIPIO, IRENEO D JR.FACILITY TYPE:
735
ADDRESS:13332 LEE DRIVETELEPHONE:
(714) 606-1087
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY: 4CENSUS: DATE:
11/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:33 PM
MET WITH:David AlipioTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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Licensing Program Analysts (LPAs) Michael Tea And Fred Arias conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea and LPA Arias was greeted and granted entry into the facility by house manager, Erminda Manez Alipio and explained the reason for the visit. Assistant Administrators (AA) David Alipio and Neome Golfo arrived shortly to assist with the visit. Facility is licensed for 4 ambulatory clients. Currently there are four clients residing.

Around 1:40 PM, LPAs Tea and Arias reviewed four client files and three staff files. Client files and staff files contained all required documentation. While reviewing client files, LPAs discovered one client to have a non-ambulatory status reported on the physician’s report. Upon review of records, the facility is up to date with required quarterly emergency disaster drills, which was last conducted on September 5, 2024. AD Mark John Alipio’s administrator certificate has an expiration date of January 2, 2025.

LPAs Tea and Arias along with the HM Alipio toured the facility at 2:44 PM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a single-story home that consists of 4 client bedrooms, 2 bathrooms, living room, dining room, kitchen, sunroom/office area and attached garage. LPAs 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 resident comfortably. Client bathrooms were checked. During facility tour, one bathroom had toxins out and LPAs advised that they should be stored and locked and made inaccessible to clients in care. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured around 113.3 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.



Annual continuation on LIC809-C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
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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Document Has Been Signed on 11/27/2024 09:03 AM - It Cannot Be Edited


Created By: Michael Tea On 11/26/2024 at 04:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SANTA VERONICA CARE VILLA

FACILITY NUMBER: 306005687

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80010(b)
Limitations on Capacity and Ambulatory Status
(b) Facilities or rooms approved for ambulatory clients only shall not be used by nonambulatory clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPAs reviewed client record and discovered physician's report of client has non ambulatory status, facility is ambulatory only. This poses an immediate health and safety risk to clients in care.
POC Due Date: 11/27/2024
Plan of Correction
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Licensee will apply new fire clearance to accept non ambulatory clients or relocate or remove client to another facility that accepts non-ambulatory residents. Licensee will notify fire department of non-ambulatory client in the facility, and provide proof of additional staff caring non ambulatory client.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Michael Tea
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 11/27/2024 09:03 AM - It Cannot Be Edited


Created By: Michael Tea On 11/26/2024 at 04:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SANTA VERONICA CARE VILLA

FACILITY NUMBER: 306005687

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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During facility tour LPAs discovered toxins and an air fresher around the bathroom. This could pose as a potential health and safety risk to clients in care.
POC Due Date: 11/27/2024
Plan of Correction
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Licensee removed toxins and cleaning solutions after LPAs discovered in the restroom. LPAs explain that disinfectants, cleaning solutions, poisons need to be stored and locked and be inaccessible to clients in care.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Michael Tea
LICENSING EVALUATOR SIGNATURE:
DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/26/2024


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 VERONICA CARE VILLA
FACILITY NUMBER: 306005687
VISIT DATE: 11/26/2024
NARRATIVE
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LPAs observed sharps locked in a kitchen drawer. LPAs also observed toxin substances to be locked and inaccessible to clients in care locked and secured underneath the kitchen sink. The fire extinguisher in the kitchen is fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating with shade and two exit gates on both sides of the facility are self-latching and operational. LPAs observed emergency supplies, food and water supply in the storage closet by the front entryway. Facility provides activities based on client interests. The clients go for walks around the neighborhood, do arts and crafts and go on outings. Clients also help with gardening and putting away dishes. At the time of annual visit, clients were seen watching tv and doing arts and crafts in their room.
LPAs reviewed medication storage and administration. Medications are stored in a locked cabinet in the living room. Medications are being administered per physician. LPAs checked P&I Funds and discovered no discrepancies. LPAs interviewed residents regarding their quality of care and spoke to staff present regarding care provided.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Assistant Administrator Neome Golfo and House Manager Erminda Manez Alipio and a copy of these reports were given to the facility along with a copy of the LIC858; 859;809-D, 9102 and Appeal Rights
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC809 (FAS) - (06/04)
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