St. John the Evangelist Care Villa

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to conduct the annual required visit. LPA was greeted and granted entry into the facility and explained the reason for the visit. Facility is licensed for 4 ambulatory clients of which 1 may be non-ambulatory with hospice waiver for 1. The facility currently has 3 clients with none on hospice. Divina Alipio has an Administrator Certificate expiring on 06/19/2026. Administrator Divina Alipio arrived during the visit. The facility appears clean and sanitary. LPA Lyman along with care staff Cathy Calas toured the facility at 8:38 AM. LPA toured the physical plant, checked food service, and reviewed facility documentation. The home consists of four client bedrooms, one shared hall restroom, client restroom, office, living room, dining room, and kitchen. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, and grab bars were secure. Water temperature measured between 113.3 and 113.9 degrees F in facility restrooms. Client 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 thermometer, tweezers and scissors as well as a first aid manual. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Smoke detectors and Carbon Monoxide detectors tested operational during today's visit. Fire extinguisher is fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating for clients. Exit gate is unlocked, self latching and operational. LPA observed ample emergency food and water supply as well as emergency packs for clients. LPA reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility provided documentation of last fire drill conducted on 06/26/2025 and drills are conducted quarterly. CONTINUED ON LIC 809C DATED 09/09/2025 Facility provides activities in the form of games, exercise and outings in the community. LPA reviewed three client files and three staff files. Client files contained required documents including admission agreements, physician reports and client appraisals. Staff files reviewed contained required documentation of health screens/ TB and criminal record clearance. Staff files reviewed contained CPR certification and required training. LPA reviewed medication storage and administration. Facility uses a medication administration record. Medications are stored in a locked cabinet and are being administered per physician order. LPA reviewed P & I money with staff. Ledgers match cash on hand. Based on the observations made during today’s visit, NO deficiencies are being cited per California Code of Regulations Title 22 Division 6. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Sep 9, 2025

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 4 COMP II Participant: Divina Joy Alipio, CEO/Administrator Interview Method: Telephone interview On 8/21/24, applicant/administrator participated in COMP II. Identification of the applicant/administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant/administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Aug 21, 2024