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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003059
Report Date: 01/08/2025
Date Signed: 01/08/2025 04:33:52 PM

Document Has Been Signed on 01/08/2025 04:33 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:
01/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Carina De La Cruz TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On 01/08/2025 Licensing Program Analyst (LPA) William Vanegas made an unannounced visit to complete the annual inspection that began on 12/30/2024. Upon LPA arrival LPA was greeted and granted entry to the facility by Care Giver (CG) Carina De La Cruz. LPA Vanegas explained the purpose of the visit and set up equipment. LPA Vanegas continued annual inspection and observed the following.

LPA Vanegas reviewed PNI with CG Carina De La Cruz and verified that all balances are accurate and up to date. LPA Vanegas reviewed four staff files and observed that all required staff files were up to date and in order. LPA Vanegas also reviewed five client files and observed the files to have all updated and required files in order.

LPA Vanegas reviewed client medications and observed them to be locked away and inaccessible to clients in care. Per LPA Vanegas review medications are being administered per physicians orders. LPA Vanegas reviewed first aid kit to have all required materials such as a thermometer, scissors, and tweezers. LPA Vanegas reviewed disaster preparedness plan and infection control plan. LPA Vanegas observed for all required postings to be posted and in the proper dimensions.

Based on the observations made during today’s inspection, deficiencies are not being cited per Title 22 Division 6 of the California Code of Regulations. 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: 01/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2025
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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