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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204954
Report Date: 06/09/2025
Date Signed: 06/09/2025 01:58:26 PM

Document Has Been Signed on 06/09/2025 01:58 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:ELEGANT CARE VILLA D-1FACILITY NUMBER:
198204954
ADMINISTRATOR/
DIRECTOR:		LODERVINE ALIPIOFACILITY TYPE:
740
ADDRESS:2741 N. BELLFLOWER BLVD.TELEPHONE:
(714) 273-7676
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY: 6CENSUS: 4DATE:
06/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Jimbo Paug and Lodervine AlipioTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On 06/09/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with staff, Jimbo Paug and explained the purpose of today’s visit. LPA was granted access to the facility. Administrator Lodervine Alipio joined LPA for the inspection shortly after. The facility is licensed to serve two (2) ambulatory and (4) non-ambulatory residents aged 60 and above. Hospice waiver approved for one (1) resident. Currently there are four (4) residents in the facility.

The facility is a single-story home located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, three (3) bathrooms, of which two (2) are private, and one (1) is shared, a living room with workspace for staff, kitchen, dining area, laundry area, an outside shaded seating area, and a detached garage.

LPA Gonzalez and Lodervine Alipio toured the entire physical plant. There were no bodies of water or obstructions on the premises. Exits/ Walkways around the home were free of debris and hazards. All residents’ bedrooms were inspected. The bedrooms had the required furniture, beds, mattresses, box springs and bedding were in good condition, adequate lighting was provided, and storage for resident’s personal belongings was observed. LPA observed the walls and floors were in good repair. Bathrooms were clean and operational and found to be within Title 22 regulations. The hot water temperature measured between 105.F and 120.F degrees. A comfortable temperature is maintained in the facility.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. The storage area for personal hygiene, cleaning supplies, toxins, and sharp objects were stored and inaccessible to residents.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Elvira Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: ELEGANT CARE VILLA D-1
FACILITY NUMBER: 198204954
VISIT DATE: 06/09/2025
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The kitchen was inspected, and sufficient perishable and non-perishable food was available and maintained properly. Fire extinguishers were charged, and smoke detectors and carbon monoxide were tested and operable. A working landline phone is available. A first aid kit along with manual was fully stocked and available. LPA noted that all required postings were on the walls.

LPA conducted a review of four (4) resident records, and two (2) staff files, and observed them to be in order and complete. The Medication Administration Records (MAR) were reviewed and found to be maintained in order. Centrally stored medications are kept locked and inaccessible to residents. The Medication Administration Records (MAR) were reviewed and found to be maintained in order. Centrally stored medications are kept locked and inaccessible to residents. The facility is current with Community Care Licensing (CCL) annual fees. Liability insurance is active with expiration date of 07/01/25.

No deficiencies were cited during this inspection visit.

An exit interview was conducted with Administrator Lodervine Alipio, and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Elvira Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2025
LIC809 (FAS) - (06/04)
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