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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006354
Report Date: 01/07/2025
Date Signed: 01/07/2025 10:18:51 AM

Document Has Been Signed on 01/07/2025 10:18 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:ST JOSEPH CARE VILLAFACILITY NUMBER:
306006354
ADMINISTRATOR/
DIRECTOR:
ALIPIO, DIVINA JOY M.FACILITY TYPE:
735
ADDRESS:6062 CERULEAN AVETELEPHONE:
(657) 352-8841
CITY:GARDEN GROVESTATE: CAZIP CODE:
92845
CAPACITY: 4CENSUS: 4DATE:
01/07/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Jameson BaconTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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On 01/07/2025 Licensing Program Analyst's (LPA's) William Vanegas and Rose Ruppert made an unannounced visit for the purposes of a case management visit in regard to an incident that occurred with a client in care. Special Incident Report (SIR) was submitted stating that client was being assisted out of his wheel chair after client's shower and had a behavioral episode. Client then had a fall off of his wheel chair. Upon arrival LPA's were greeted and granted entry by Caregiver (CG) Jameson Bacon and explained the purpose of the visit. CG stated that administrator (AD) Divina Alipio would arrive shortly to speak with us.

Upon AD arrival client file, client discharge paperwork, and staff files were provided to LPA Vanegas for review. LPA Vanegas reviewed all files and observed the following. According to discharge paper work client in care was diagnosed with a nasal fracture and obtained four stiches on the left eyebrow and four stiches on his nose. Per LPA review according to client's preplacement appraisal client is diagnosed with Organic Mental Disorder with Aggression (Psychosis) and Bipolar disorder.

Per LPA Vanegas review of staff records (CG) Sarsi De Venecia has been trained on resident rights, resident care and communication, bathing grooming and dressing, and Dementia care. Per LPA Vanegas review (CG) Larry Acosta has been trained on Resident rights, resident care and communication, bathing grooming and dressing as well.

LPA Vanegas interviewed the following staff Sarsi De Venecia, Crisanto Dupal and AD Divina Alipio. Staff member Larry Acosta was not available to interview on today's date. LPA Vanegas attempted to interview client in care however client refused to speak with LPA's.

Based on today's observations no health or safety concerns were noted and no deficiency's were cited. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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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