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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006301
Report Date: 07/06/2023
Date Signed: 07/06/2023 02:42:14 PM

Document Has Been Signed on 07/06/2023 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:ST. GABRIEL CARE VILLAFACILITY NUMBER:
306006301
ADMINISTRATOR:ALIPIO, DIVINA JOY MAPILIFACILITY TYPE:
740
ADDRESS:6081 CERULEAN AVETELEPHONE:
(714) 248-9330
CITY:GARDEN GROVESTATE: CAZIP CODE:
92845
CAPACITY: 4CENSUS: 0DATE:
07/06/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Divina Alipio
Davidson Alipio		TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA met with Licensee Davidson Alipio and designated Administrator (AD) Divina Alipio. An application to operate a Residential Care Facility for Elderly (RCFE) for (4) capacity, (3) ambulatory, (1) non-ambulatory, and (0) bedridden residents was received by CCL on 1/09/2023.

Structure:
The facility is a one-story house with four resident bedrooms, two bathrooms, living room, kitchen, dining area, sun room, and attached two car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the entranceway. There is a backyard with an exit gate each side of the house. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard.

Resident Bedrooms
All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets. LPA observed all windows were screened.

Signal system
There is no signal system.

Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked underneath the kitchen sink.

Medications, First-Aid Kit & Book:
Medication will be stored in a locked file cabinet. First aid kit is stored above medication file cabinet. The first aid kit has all the required elements.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ST. GABRIEL CARE VILLA
FACILITY NUMBER: 306006301
VISIT DATE: 07/06/2023
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Resident & Staff Files:
Records will be kept locked with medication.

Pool/Jacuzzi:
No bodies of water were observed.

Fire Extinguisher:
Fire extinguisher is fully charged.

Reading Material, Games, Equipment & Materials:
The facility will receive daily newspaper for residents and puzzles are also available. Facility will also utilize day programs for most residents.

Fire clearance:
Was approved by a fire inspector of Orange County Fire Authority on 04/17/2023. Special conditions noted, “Bedrooms 1,3, and 4 approved for ambulatory clients only. Bathroom 2 approved for ambulatory and non-ambulatory clients only.”

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements.

Bedrooms Staff:


There is no staff bedroom.

Bathrooms:
All bathrooms have working plumbing, grab bars, and non-skid mats. Hot water measured at 107.0 degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen was stored in the hallway storage.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ST. GABRIEL CARE VILLA
FACILITY NUMBER: 306006301
VISIT DATE: 07/06/2023
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Emergency Phone Numbers, Exit Plan & Menu:
Posted and available, means of exiting, emergency phone numbers and food menu.

Food Service:
A supply of 2-day perishable and 7-day of non-perishable food will be maintained on hand.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors tested operational.

Appliances:
Gas five burner stove with 1 oven, 1 refrigerator, dish washer, microwave, washer, and dryer are operational.

The designated AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. An xxit interview was conducted and a copy of this report was provided to designated AD.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023
LIC809 (FAS) - (06/04)
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