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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006038
Report Date: 11/19/2021
Date Signed: 11/19/2021 02:18:35 PM

Document Has Been Signed on 11/19/2021 02:18 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 TERESA CARE VILLAFACILITY NUMBER:
306006038
ADMINISTRATOR:ALIPIO, MARK JOHN MFACILITY TYPE:
735
ADDRESS:12782 SPRING STTELEPHONE:
(714) 622-5979
CITY:GARDEN GROVESTATE: CAZIP CODE:
92845
CAPACITY: 4CENSUS: 0DATE:
11/19/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mark Alipio, Davina Alipio, and Myrna AlipioTIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Kimberly Lyman made an announced pre-licensing visit. LPA identified herself and discussed the purpose of the visit with Licensees/ Administrators Mark Alipio, Davina Alipio, and Myrna Alipio. An initial application to operate an Adult Residential Facility was submitted to CCL on 11/04/2021 for a capacity of 4 ambulatory residents. Administrator Mark Alipio has a current administrator certificate expiring on 01/02/2023. There are no clients in care during today's visit. Facility has covid signage in the facility and LPA observed the screening/ sanitation station in the entrance of the facility.
LPA Lyman along with Licensee/ Administrators toured the facility at 9:10 AM and observed the following:
Structure: Facility is a one story, 4 bedroom, 2 bathroom house with an attached garage and a light creme exterior. The exit gates are closed and unlatched. Living Room/ Dining Room: Adequate seating is available in the dining room, living room, and family room. Bedrooms Clients: All bedrooms are single occupancy. All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms: All client restrooms have a working toilet/ wash basin as well as paper towels in all restrooms. There is a non-skid surface in bath/ shower. There are hand washing signs in all restrooms. Linens & Hygiene Supplies: Linen supply is in ample supply for clients in care. Emergency Phone Numbers and Exit Plan: Posted in the entrance area of the facility. Food Service: Facility has ample 7 day non-perishables/ 2 day perishables in the kitchen. LPA observed a sample menu. Smoke Detectors: Smoke detectors/ carbon monoxide detectors are centrally wired and were tested operational. Fire extinguishers are fully charged. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins: Stored in a locked area in the kitchen with the sharps. Water Temperature: Tested and recorded between 118 and 120 degrees F.in facility bathrooms. Emergency Supplies: LPA observed ample emergency food, water, and emergency supplies. Facility has the emergency disaster plan posted and has completed the mitigation plan. Medications, First-Aid Kit & Book: First aid kit observed contained all required items. LPA observed a first aid manual. Medication to be stored and locked in a locked cabinet in the living room. Facility uses a medication administration record. CONTINUED ON LIC 809C DATED 11/19/2021.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2021
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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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 TERESA CARE VILLA
FACILITY NUMBER: 306006038
VISIT DATE: 11/19/2021
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Resident & Staff File: Records to be stored in a cabinet in living room. Reading Material, Games, and Equipment: Facility to obtain entertainment activities according to client's preference. Facility activity schedule includes games and outings in the community. Backyard: LPA observed a clean, safe backyard with shaded seating for clients. Fire Clearance: Approved for 4 ambulatory residents on 08/26/2021.

The facility is ready to be licensed. Component III conducted during the visit.

Licensee advised to post the "Let Us No" poster in entrance of facility at regulation size.

An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
LIC809 (FAS) - (06/04)
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