306005256-6-12-2025-22-AS-MTEA-DHKW3A-20250612165538

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005256
Report Date: 06/12/2025
Date Signed: 06/12/2025 04:55:48 PM

Document Has Been Signed on 06/12/2025 04:55 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:	HEARTWELL CARE VILLA		FACILITY NUMBER:	306005256
ADMINISTRATOR/ DIRECTOR:	ALIPIO JR, IRENEO D		FACILITY TYPE:	740
ADDRESS:	5591 NORMA DRIVE		TELEPHONE:	(714) 622-5471
CITY:	WESTMINSTER	STATE: CA	ZIP CODE:	92683
CAPACITY: 4		CENSUS: 4	DATE:	06/12/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:30 PM
MET WITH:	David Alipio		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At around 1:30 PM, LPA Tea was greeted and granted entry into the facility by house manager, Ryan Tanisita and explained the reason for the visit. The Administrator, David Alipio arrived shortly after to assist with the visit. Facility is licensed for 4 non-ambulatory residents. Currently there are four residents living at the facility.

At 1:45 PM LPA Tea reviewed four resident files and three staff files. Residents files and staff files contained all required documentation.

LPA Tea along with AD Alipio toured the facility. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of four resident bedrooms, staff area, three full bathrooms, living room, dining room, kitchen and an attached garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and showers were free of mold/mildew. Water temperature measured between 152. 4 degrees and 130.4 F degrees, which is very high. Administrator and staff attempt to fix and adjust the water boiler, but it was still high. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including bandages, dressing, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen drawer. LPA also observed toxin substances to be secured and locked and inaccessible to clients in the kitchen and garage. Fire extinguisher is fully charged. The facility’s last fire drill was conducted on April 01, 2025.

Continuation on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Michael Tea
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025

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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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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Document Has Been Signed on 06/12/2025 04:55 PM - It Cannot Be Edited

Created By: Michael Tea On 06/12/2025 at 04:29 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HEARTWELL CARE VILLA	FACILITY NUMBER: 306005256
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(3)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, the water temperature was very high, reaching 152.4 F degrees. The facility staff tried to adjust the temperature but it was still too high. This poses as a potential health and safety risk to residents in care.
	POC Due Date: 06/26/2025
	Plan of Correction
1 2 3 4	Facility will replace the water tank/boiler or fix the plumbing. Facility will provide proof of water temperatures reading to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:

	Michael Tea
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025

LIC809 (FAS) - (06/04)

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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: HEARTWELL CARE VILLA	FACILITY NUMBER: 306005256
	VISIT DATE: 06/12/2025

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Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating with shade. There are two exit gates, one on each side of the house, they are self-latching and operational. LPA observed emergency food, water and supplies in the garage. For activities residents do puzzles and arts and crafts. The staff takes residents for walks and outings such as having picnics at the park and going shopping. During the visit LPA observed residents watching TV and about to eat dinner.

LPA reviewed medication storage and administration. Medications are stored in a locked cabinet in the staff area. Medications are being administered per physician order. P&I Funds were reviewed and there were no discrepancies. LPA interviewed residents regarding their quality of care and spoke to staff present regarding care provided.

The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with administrator, David Alipio and a copy of this report LIC809, 809-C, LIC858, LIC859, LIC809-D was read and provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Michael Tea
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2025

LIC809 (FAS) - (06/04)

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