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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006038
Report Date: 11/04/2022
Date Signed: 11/04/2022 12:39:45 PM

Document Has Been Signed on 11/04/2022 12:39 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: 4DATE:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Samuel Jones- House Manager, Divina Alipio - Administrator, Mark Alipio - Licensee TIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into facility by House Manager Samuel Jones. Administrator Divina Alipio arrived at 11:33 AM and Licensee Mark Alipio arrived at 11:49 AM.

At 11:30 AM, LPA toured facility with House Manager Samuel Jones. Facility has 3 clients present during today’s visit. Facility is a 4 bedroom, 2 bathroom, single story home with an attached garage. LPA observed a screening and sanitizing station at entrance of the facility. LPA observed clients in the living room. Facility appears clean and sanitary. All clients rooms had required elements, including bed, chair, closet space and ample lighting. Restrooms are stocked with soap and have hand washing postings. Facility has 2 refrigerators with ample food supply. LPA observed facility has emergency food and water supply. Facility has a secured location for client medication and files. LPA toured the outside grounds and observed outside visitation area. Exit gates are unlocked and self latching. Facility has a plan for covid testing clients and staff as needed as well as a plan for isolation. LPA observed a 4 weeks supply of PPE. LPA reviewed all clients' files and all contained required documentation including updated emergency information. All staff and clients are fully vaccinated for COVID-19.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
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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