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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005256
Report Date:
06/30/2021
Date Signed:
06/30/2021 02:42:19 PM
Document Has Been Signed on
06/30/2021 02:42 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:
HEARTWELL CARE VILLA
FACILITY NUMBER:
306005256
ADMINISTRATOR:
ALIPIO JR, IRENEO D
FACILITY TYPE:
740
ADDRESS:
5591 NORMA DRIVE
TELEPHONE:
(714) 606-1087
CITY:
WESTMINSTER
STATE:
CA
ZIP CODE:
92683
CAPACITY:
4
CENSUS:
3
DATE:
06/30/2021
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
02:02 PM
MET WITH:
David Alipio
TIME COMPLETED:
02:51 PM
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Licensing Program Analyst (LPA) Jim August conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into the facility by Caregiver Patrick Florendo and explained the reason for the visit. Administrator David Alipio arrived shortly after.
LPA August toured the facility. There are three clients residing in the facility and no active covid-19 cases. LPA observed three clients on site. All clients appeared clean and well taken care of. LPA observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed had ample soap/ sanitizer and appeared clean. Client bedrooms appeared clean and sanitary and had all required components. Facility is taking client's temperatures daily and documenting results. LPA observed the emergency disaster and evacuation plans. Facility has back-up emergency food and water supply as well as PPE supplies. Facility has completed the LIC808 Mitigation Plan. The facility is still conducting covid-19 testing with all staff as required by the latest guidance.
No citations noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME
:
Sheila Santos
LICENSING EVALUATOR NAME
:
James August
LICENSING EVALUATOR SIGNATURE
:
DATE:
06/30/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/30/2021
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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