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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003059
Report Date: 02/23/2022
Date Signed: 02/23/2022 02:55:45 PM

Document Has Been Signed on 02/23/2022 02:55 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ELEGANT CARE VILLA IIIFACILITY NUMBER:
306003059
ADMINISTRATOR:MYRNA ALIPIOFACILITY TYPE:
740
ADDRESS:1640 MELISSA WAYTELEPHONE:
(714) 776-2092
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 6CENSUS: 4DATE:
02/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Devinajoy Alipio, Jonar Medrano, Iona De VeneciaTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff Jonar and Iona and explained the reason for the visit. Staff contacted via phone call Administrator (AD) Divina Joy Alipio who arrived at the facility. LPA observed all required postings on the wall throughout the facility AD Alipio states she will have the See Something (Pub 475) poster enlarged. AD Divinajoy Alipio has a current administrators certificate that expires on 06/19/2022. LPA was screened and temperature checked before entering the facility. LPA observed a screening log book, and temperature thermometer for screening clients and visitors. At 2:25pm LPA toured the facility with AD Alipio. There were four residents in care at the facility. All appeared to be happy and well taken care of. LPA began the tour checking client rooms and bathrooms. Client rooms have the necessary requirements, night stand, chair, lamp and dresser. Bathrooms were operational and clean. LPA measured the bathroom water temperature at 111.5 degrees Fahrenheit. All medications were locked and secure in a cabinet near the dining room. The facility had a two day supply of perishable food items and seven days supply of nonperishable food items. There was a first aid kit equipped with all required items. The stove was clean and all burners were operational. Knives were locked in a drawer. All hazardous chemical are locked under the kitchen sink. The facility has adequate PPE supply of gloves, N95 mask, surgical mask, and hand sanitizers. LPA observed extra linen, emergency food and water supply. LPA toured the backyard and observed an exit gates on the side of the house that was self closing and self latching. LPA observed a shaded visitation area in the backyard equipped with tables and chairs for the residents in care. There were no bodies of water observed. There were some loose tools and long wooden sticks that were removed and secured in the garage. All smoke detectors were tested and are operational.
No deficiencies are being cited during todays visit. An exit interview conducted and a copy of the report was provided to the Administrator Divinajoy Alipio.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2022
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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