306006354-10-31-2023-22-AS-CGUZ-CX5P47-20231031105841

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006354
Report Date: 10/31/2023
Date Signed: 10/31/2023 10:58:53 AM

Document Has Been Signed on 10/31/2023 10:58 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ST JOSEPH CARE VILLA		FACILITY NUMBER:	306006354
ADMINISTRATOR:	ALIPIO, DIVINA JOY M.		FACILITY TYPE:	735
ADDRESS:	6062 CERCULEAN AVE		TELEPHONE:	(657) 352-8841
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92845
CAPACITY: 4		CENSUS: 0	DATE:	10/31/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Divina Alipio		TIME COMPLETED:	11:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA met with designated Administrator (AD) Divina Alipio. An application to operate a Adult Residential Facility (ARF) for (4) capacity, (3) ambulatory, (1) non-ambulatory, and (0) bedridden clients was received by CCL on 5/04/2023. Structure: The facility is a one-story house with four client bedrooms, three bathrooms, two living areas, kitchen, dining area, an additional bedroom used for storage and attached two car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the entranceway. There is a backyard with an exit gate on one side of the house. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard. Resident Bedrooms All client bedrooms had the required furnishings. LPA observed all beds had linens and blankets. LPA observed all windows were screened. Signal system There is no signal system. Toxins All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients and will be stored and locked in the garage. Medications, First-Aid Kit & Book: Medication will be stored in a locked file cabinet. First aid kit is also stored in medication file cabinet. The first aid kit has all the required elements.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

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: ST JOSEPH CARE VILLA	FACILITY NUMBER: 306006354
	VISIT DATE: 10/31/2023

NARRATIVE

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Resident & Staff Files:
Records will be kept in a cabinet next to medication.

Pool/Jacuzzi:
No bodies of water were observed.

Fire Extinguisher:
Fire extinguisher is fully charged.

Reading Material, Games, Equipment & Materials:
The facility will provide board games, books, art supplies and other recreational materials for the client’s use.
Fire clearance:
Was approved by a fire inspector of Orange County Fire Authority on 06/12/2023. Special conditions noted, “non-ambulatory approved for bedroom #3 only.”

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements.

Bedrooms Staff:

There is no staff bedroom.

Bathrooms:
All bathrooms have working plumbing. Hot water measured at 106.0 degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen was stored in the hallway storage.

Emergency Phone Numbers, Exit Plan & Menu:
Posted and available, means of exiting, emergency phone numbers and food menu.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

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: ST JOSEPH CARE VILLA	FACILITY NUMBER: 306006354
	VISIT DATE: 10/31/2023

NARRATIVE

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Food Service:
A supply of 2-day perishable and 7-day of non-perishable food was observed and will be maintained on hand.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Electric burner stove with oven, refrigerator, dish washer, microwave, washer, and dryer are operational.

The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided to designated AD.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

LIC809 (FAS) - (06/04)

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