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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204954
Report Date: 06/24/2023
Date Signed: 06/24/2023 12:10:21 PM

Document Has Been Signed on 06/24/2023 12:10 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:ELEGANT CARE VILLA D-1FACILITY NUMBER:
198204954
ADMINISTRATOR:JOY ALEOPIOFACILITY TYPE:
740
ADDRESS:2741 N. BELLFLOWER BLVD.TELEPHONE:
(714) 606-1087
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY: 6CENSUS: 3DATE:
06/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:32 AM
MET WITH:David AlipioTIME COMPLETED:
11:59 AM
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On 06/24/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with assistant administrator David Alipio. LPA explained the purpose of today’s visit. The facility is licensed to operate for (4) non-ambulatory of which (2) maybe ambulatory elderly adults ages 60 and above. Currently, the facility has no hospice residents in care. The facility is approved for (1) hospice resident. The residents are Harbor Regional and South-Central Regional consumers.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: (4) residents' rooms, (3) bathrooms, a living area, a dining area, a kitchen, an outside seating area, and a garage.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 105.0 degrees F. A comfortable temperature of 74 degrees F. was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. The facility maintained an emergency food and water supply. A fire extinguisher was charged. A review of the Medication Records Administration (MAR) was observed to be maintained in place.

(Evaluation Report continues LIC 809-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2023
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ELEGANT CARE VILLA D-1
FACILITY NUMBER: 198204954
VISIT DATE: 06/24/2023
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 06/04/23 and the earthquake drill on 06/05/23. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 07/01/22 - 07/01/23. The facility annual license fees are current.

An audit of resident #1-#3 (R1-R3) service files and staff #1-#4 (S1-S4) personnel files revealed to be complete. An audit of the resident's P&I is maintained in order and complete. Interviews were conducted with (3) residents and (3) staff. The facility has the current administrator's certification on file for Joy Alipio Administrator Certificate: #6037750740 Exp. 06/27/2024 and Davidson Alipio Administrator Certificate: #6040079740 Exp 07/05/2023.

No deficiencies during this inspection visit.

An exit interview was conducted with David Alpio and a copy of the report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2023
LIC809 (FAS) - (06/04)
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