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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850212
Report Date: 01/25/2022
Date Signed: 01/26/2022 06:29:06 PM

Document Has Been Signed on 01/26/2022 06:29 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-CARE HOME IIIFACILITY NUMBER:
425850212
ADMINISTRATOR:RUST, JESSICAFACILITY TYPE:
740
ADDRESS:965 ROBERT LANETELEPHONE:
(805) 928-1061
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY: 6CENSUS: 4DATE:
01/25/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jennifer VillarosTIME COMPLETED:
12:01 PM
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Licensing Program Analysts (LPA) Diaz conducted a pre-licensing visit to the facility above at 11:00am. LPA met with Jennifer Villaros. The applicant has obtained fire clearance for (5) non-ambulator and (1) bedridden residents, for a total capacity of six (6) Residents.

Beginning at 11:08am, LPA inspected the proposed facility for Fire Safety, Personal Accommodations, and Food Service. All hard-wired smoke alarms were functioning properly at this time. The carbon monoxide detector was functioning. LPA observed one fire extinguisher to be fully charged. Paint, windows, blinds, and floors are in good repair. There are no firearms on the premises. The common living and dining areas are clean and properly furnished. A working telephone is present. The facility has a comfortable temperature of 71 degrees.

The proposed facility has 4 resident bedrooms total. The resident bedrooms were furnished and contained beds, chairs, bedside tables and lamps. All beds have sheets, pillows, and mattress pads. There is also an ample supply of linen, towels and paper products. The proposed facility has (2) bathrooms for resident use. LPA observed a night-light present in the main hallway. Hot water measured at 116. degrees Fahrenheit at The kitchen contained a sufficient supply of dishes, glasses and utensils and aseven-day supply of non-perishable food was present. A locked medication cabinet and First aid kit was observed to be complete. There is space to lock chemicals in the garage, under the bathroom sink and kitchen sink. Sharp items are stored in a locked kitchen drawer. The laundry room is located in the garage and supplies will be stored in the locked garage cabinets. The building and grounds are free from hazard.

Exit interview conducted and report issued.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Arien Diaz
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2022
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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