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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881248
Report Date: 07/20/2023
Date Signed: 07/20/2023 01:08:11 PM

Document Has Been Signed on 07/20/2023 01:08 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
Lookup Error,
, CA
FACILITY NAME:WESTFIELD VILLA GARDENSFACILITY NUMBER:
331881248
ADMINISTRATOR:MARIA JASMIN DOLORESFACILITY TYPE:
740
ADDRESS:3863 WEST RAMSEY STTELEPHONE:
(951) 849-7521
CITY:BANNINGSTATE: CAZIP CODE:
92220
CAPACITY: 50CENSUS: 30DATE:
07/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Maria Jasmin Dolores, AdministratorTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to interview residents in care. The purpose for the interviews is for the investigation of complaint # 18-AS-20230717104706, having to do with an unrelated facility. The LPA met with Maria Jasmin Dolores, Administrator, and informed her of the purpose for the visit.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023
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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