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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425800662
Report Date: 05/11/2022
Date Signed: 05/11/2022 03:15:38 PM

Document Has Been Signed on 05/11/2022 03:15 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:VILLA BLANCAFACILITY NUMBER:
425800662
ADMINISTRATOR:INNA LYUTKO & NONNA ROZHKOFACILITY TYPE:
740
ADDRESS:6272 AVENIDA GANSOTELEPHONE:
(805) 683-2000
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY: 6CENSUS: 5DATE:
05/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Inna Lyutko & Nonna RozhkoTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Toan Luong conducted an unannounced One Year Infection Control Annual visit to the facility. LPA met with Administrators Inna Lyutko and Nonna Rozhko and explained the purpose of the visit.

LPA was screened at the entrance and toured the facility. At 2:10 p.m., LPA discussed items in the Infection Control Module and noted that staff have not been fit tested with N95 masks. All other items in the Infection Control Module was checked as yes. Infection Control Module was addressed with administrators to satisfaction.

LPA conducted exit interview with administrators and emailed a copy of today's report and appeal rights to the facility.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Toan Luong
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2022
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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