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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320277
Report Date: 04/19/2022
Date Signed: 04/19/2022 10:55:50 AM

Document Has Been Signed on 04/19/2022 10:55 AM - 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:LEGACY VILLA SENIOR CAREFACILITY NUMBER:
198320277
ADMINISTRATOR:CLARKE, STEPHENFACILITY TYPE:
740
ADDRESS:21012 DOBLE AVENUETELEPHONE:
(310) 418-7938
CITY:TORRANCESTATE: CAZIP CODE:
90502
CAPACITY: 6CENSUS: 0DATE:
04/19/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Stephen Clarke, Administrator
Teresita Bautista, Licensee		TIME COMPLETED:
10:55 AM
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Component II completion: Successful

Facility Type: Residential Care Facility for Elderly (RCFE)
Application Type: Initial
Capacity:6
Census (if any clients in care): none
COMP II Participants: Stephen Clarke, Administrator
Teresita Bautista, Licensee
Interview Method: Telephone interview

On April 19, 2022, Applicant and Administrator participated in COMP II. Identification of the Applicant and Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicant and Administrator confirmed the understanding of the California Code Title 22 Regulations.

During COMP II, CAB analyst confirmed Applicant and 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 Rrovisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Administrator and Applicant. Copy of report sent via email PDF and informed to return sign copy by close of business today.
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Celia Phomphachanh
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
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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