306003059-1-13-2026-22-AS-WVAS-DQASJE-20260113125500

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003059
Report Date: 01/13/2026
Date Signed: 01/13/2026 12:55:20 PM

Document Has Been Signed on 01/13/2026 12:55 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ELEGANT CARE VILLA III		FACILITY NUMBER:	306003059
ADMINISTRATOR/ DIRECTOR:	MYRNA ALIPIO		FACILITY TYPE:	740
ADDRESS:	1640 MELISSA WAY		TELEPHONE:	(714) 776-2092
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92802
CAPACITY: 6		CENSUS: 3	DATE:	01/13/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Davina Alipio (Assistant Administrator)		TIME VISIT/ INSPECTION COMPLETED:	12:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On today's date LPA William Vanegas conducted an unannounced visit for the purposes of completing an annual inspection. Upon arrival LPA Vanegas was greeted and granted entry to the facility by Care Giver (CG) Estela De Venecia. LPA William Vanegas explained the purpose of the visit and began a tour of the facility and observed the following. LPA Vanegas observed the facility to be a one storied building with five bedrooms all five bedrooms are used for residents in care. The facility has two bathrooms that are used for residents in care, and has one shared bathroom for resident and guests. The facility has an attached two car garage, and a large backyard. LPA Vanegas observed the kitchen area to be clean and sanitary. LPA Vanegas observed a gas stove, refrigerator, dishwasher, and microwave in the kitchen area and all tested operational. LPA Vanegas observed a two day supply of perishable food and a seven day supply of non-perishable food and a sufficient amount of water on hand and available to residents in care and staff in case of an emergency. LPA Vanegas observed resident bedrooms to be clean and sanitary. Bedrooms were observed to have all required furnishings such as a chest drawer, bed, clean linens in good repair; meaning no strains or tears, a closet for storage of personal items, as well as a reading lamp. LPA Vanegas observed rooms to be large enough to walk about freely, and no obstructions blocking the doors or entry ways. LPA Vanegas observed all required posters displayed along the entry way and hallways including PUB475 sign and residents rights posted. LPA Vanegas observed all resident restrooms to be clean and free of any mildew and debris. LPA Vanegas observed water faucets, and toilets to be operable and bathroom shower had grab bars, and slip resistant floors. Water temperature tested between 106.7 and 108.8 degrees. CONTINUED ON LIC809C

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2026

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ELEGANT CARE VILLA III	FACILITY NUMBER: 306003059
	VISIT DATE: 01/13/2026

NARRATIVE

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LPA Vanegas observed all smoke and carbon monoxide detectors to be in good repair and tested operational. LPA Vanegas observed fire extinguishers to be fully charged and up to date. LPA Vanegas observed the facility to have an updated infection control plan, disaster preparedness plan, and a devise that is available for resident use for tele health visits and to conduct video calls with family if needed.

LPA Vanegas toured the outside of the facility and observed an outdoor shaded sitting area, the backyard appeared to be in clean and sanitary condition. LPA Vanegas observed side doors to be self latching and unlocked. LPA Vanegas observed garage to be clean and in good repair as well.

LPA Vanegas reviewed three staff files, and three resident files. All files (Staff and Resident) had all required documents and all were up to date. Staff training has been completed and documented. LPA Vanegas observed first aid kit to have all required items such as scissors, tweezers, bandages, a thermometer, and a first aid manual. LPA Vanegas reviewed P&I with AD and observed all balances to be accurate, and up to date.

LPA Vanegas reviewed medications and medication administration record (MAR) with AD and observed all medications to be documented in the MAR and being administered per physicians orders. Based on observations made during today's inspection, no deficiencies will be issued, per tittle 22 of the California Code of Regulations. An exit interview was conducted with AD Davina Alipio and a copy of this report was provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2026

LIC809 (FAS) - (06/04)

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