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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003059
Report Date: 10/11/2023
Date Signed: 10/11/2023 12:57:42 PM

Document Has Been Signed on 10/11/2023 12:57 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
ORANGE COUNTY ASC, 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: DATE:
10/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Divina Alipio - Co-AdministratorTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at Elegant Care Villa III to conduct an unannounced Required 1 Year Inspection. LPA arrived at the facility at 10:40am, LPA was greeted and granted entry by Caregivers (CG) Jonar Medrano and Carina De La Cruz. Co-Administrator (CAD) Divina Alipio joined the inspection at 11:30am.

The facility is a one-story home with five resident bedrooms, two bathrooms, living room, kitchen, dining room, backyard, and an attached two car garage. There is one exit gate on the side of the house. There is one shaded seating area in the backyard. LPA did not observe any hazards or obstacles in back yard. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients and will be stored and locked in cabinets in the kitchen and garage. Medication and Files are stored in a locked cabinet in the dining room. First aid kit is stored on this cabinet. LPA reviewed three out of six client files and medication. LPA reviewed four staff files. LPA interviewed two staff and two clients. Other clients were unavailable. The fire extinguisher is fully charged. LPA observed service tag to indicate the extinguisher was last serviced on 7/17/23. The facility has books, planned outings to the park/stores and group therapeutic exercise. All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 116.6 degrees Fahrenheit in bathroom 1 and 109.9 degrees Fahrenheit in bathroom 2. Extra linen and hygiene supplies are stored in the hallway cabinets. Emergency Phone Numbers, Exit Plan & Menu are posted for review. There is a 2-day supply of perishable food and 7-day supply of non-perishable food on hand. Smoke and carbon monoxide detectors tested operational. Stove/oven, refrigerator, dishwasher, microwave, washer/dryer are operational.
Based on the observations made during today's visit, no deficiencies are being cited as per Title 22 Division 6 Chapter 2 of the California Code of Regulations. An exit interview was conducted with Co-Administrator Divina Alipio, and a copy of this report was provided.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2023
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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