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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204954
Report Date: 05/20/2021
Date Signed: 05/20/2021 12:45:45 PM

Document Has Been Signed on 05/20/2021 12:45 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ELEGANT CARE VILLA D-1FACILITY NUMBER:
198204954
ADMINISTRATOR:IRENEO ALIPIOFACILITY TYPE:
740
ADDRESS:2741 N. BELLFLOWER BLVD.TELEPHONE:
(714) 606-1087
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY: 6CENSUS: 3DATE:
05/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Joy AlepioTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Jade Jordan conducted an unannounced Annual inspection visit and infection control inspection to the above facility. LPA was met by Joy, Administrator and the purpose of today’s visit was explained.

There are currently (3) three Regional Center consumers in placement. All (3) clients are Non-ambulatory. The facility is a single story structure located in a residential neighborhood. It consists of the following: 4 bedrooms, 3 bathrooms, living room, kitchen, dining room, laundry area, and detached garage.

LPA and Administrator toured the entire facility inside and out. Documents are posted as mandated by the DPH and CCLD. Bedrooms 1, 2, 3 are occupied by clients and contain the mandated furniture. Bedroom 4 is a vacant bedroom. The (3) bathrooms are clean and operational. First aid and manual are incompliance. Smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to clients. Medications are current. A comfortable temperature is maintained in the facility. Ample supply of perishable and nonperishable food, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to clients, 1 fire extinguisher are fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, sanitizer/soap in the in bathrooms and additional sanitation supplies in a locked cabinet located in the office. LPA observed staff wearing masks, isolation rooms are the clients private rooms and required postings throughout the facility. The facility has an approved Mitigation plan. Visitors are logged and checked. The clients vitals are checked and logged 1x a day, if no symptoms are present.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ELEGANT CARE VILLA D-1
FACILITY NUMBER: 198204954
VISIT DATE: 05/20/2021
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According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Joy Alepio, Administrator and copy of report provided.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jade Jordan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
LIC809 (FAS) - (06/04)
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