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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003059
Report Date: 12/30/2024
Date Signed: 01/08/2025 01:47:08 PM

Document Has Been Signed on 01/08/2025 01:47 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ELEGANT CARE VILLA IIIFACILITY NUMBER:
306003059
ADMINISTRATOR/
DIRECTOR:		MYRNA ALIPIOFACILITY TYPE:
740
ADDRESS:1640 MELISSA WAYTELEPHONE:
(714) 776-2092
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 6CENSUS: 5DATE:
12/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Carina De La Cruz TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 12/30/2024 Licensing Program Analyst (LPA) William Vanegas made an unannounced visit for the purposes of an annual inspection. Upon arrival LPA Vanegas was greeted and granted entry by Care Giver (CG) Carina De La Cruz. LPA Vanegas explained the purpose of the visit and set up equipment once entry was granted LPA Vanegas began a tour of the facility at 1:47PM and observed the following.

This is a one storied home with five bedrooms, and two bathrooms, and an attached two car garage. LPA Vanegas observed kitchen to be clean and sanitary, LPA Vanegas observed gas stove, microwave, and dishwasher testing operational. LPA Vanegas observed washer and dryer to be operational. LPA Vanegas observe client bedrooms to be clean and sanitary and have all the required furnishings such as a lamp, night stand, chair, bed, and appropriate storage space. LPA Vanegas observed linens to be in good repair meaning no tears or strains.

LPA Vanegas observed resident restrooms to be clean and free of debris, faucets and toilets tested to be operational water temperature tested between 111.2-114.3 degrees. LPA Vanegas observed smoke and carbon monoxide detectors to be operational. Fire extinguisher was observed to be fully charged and up to date.

LPA Vanegas conducted a tour of the backyard and observed all emergency exits to be free of obstructions and side gates to be unlocked. LPA Vanegas observed a shaded seating area and available for resident use as requested.

LPA Vanegas advised that due to time constraints annual visit would have to end and would have to be completed at a later date. Based on today's observations no deficiency's will be cited. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2024
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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