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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201313
Report Date: 01/23/2025
Date Signed: 01/23/2025 12:01:15 PM

Document Has Been Signed on 01/23/2025 12:01 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:VILLA NUEVA CARE HOME 3FACILITY NUMBER:
079201313
ADMINISTRATOR/
DIRECTOR:		LARGOZA, SHIRLEYFACILITY TYPE:
740
ADDRESS:2560 CEDRO LANETELEPHONE:
(925) 300-3778
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY: 6CENSUS: 6DATE:
01/23/2025
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Licensee Mylin PerdiguerraTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On 1/23/2025 at 8:00 AM, Licensing Program Analyst (LPA) James Sampair arrived for this unannounced Post Licensing Inspection. Upon entry to the facility, the LPA informed Caregiver Paquito (Lito) Balbuena of the purpose of the visit. Licensee Mylin Perdiguerra arrived at approximately 10:15 AM.

The LPA toured the facility inside and outside. The LPA inspected the kitchen, common areas, bedrooms, bathrooms, and the exterior of the facility. The facility was clean, appropriately furnished, and well lit. More than the 2 days of perishable and 7 days of nonperishable food supplies were available. The body of water on the facility grounds was fully enclosed and the gate was locked.
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Medications are centrally stored. Bathrooms and showers were observed to be fully functioning and clean. Carbon monoxide and smoke detectors were operational. The fire extinguisher was last replaced on 05/21/2024. Inside temperature was 67.0 degrees Fahrenheit and the hot water temperature was 113.5 degrees Fahrenheit.

The LPA reviewed 5 resident and 5 staff files.

1 Type-A citation issued (refer to LIC 809-D).

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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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Document Has Been Signed on 01/23/2025 12:01 PM - It Cannot Be Edited


Created By: James Sampair On 01/23/2025 at 11:51 AM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: VILLA NUEVA CARE HOME 3
FACILITY NUMBER: 079201313

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Lysol was in unlocked cabinet under sink in kitchen, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/24/2025
Plan of Correction
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Correction during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


LIC809 (FAS) - (06/04)
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