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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850301
Report Date: 10/13/2022
Date Signed: 10/10/2023 09:11:48 AM

Document Has Been Signed on 10/10/2023 09:11 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:VILLARIANA CAREFACILITY NUMBER:
565850301
ADMINISTRATOR:BUSCH, HELEN ROSE T.FACILITY TYPE:
740
ADDRESS:4731 READING DRIVETELEPHONE:
(319) 360-1230
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: DATE:
10/13/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Applicant/Administrator - Helen Rose T. BuschTIME COMPLETED:
10:30 AM
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COMP II by CAB successfully completed

Facility Type: Residential Care Facility for the Elderly (RCFE)
Application Type: Initial
Capacity: 6
Census (if any clients in care): No
Method: Telephone call with CAB
COMP II Participants: Applicant/Administrator - Helen Rose T. Busch

On 10/13/22, applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant/administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant/administrator confirmed the understanding of Title 22. Component II was successfully completed.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Staff qualifications and responsibilities
3. Applicant and Administrator qualifications
4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions
5. Grievances, Complaints, Community resources
6. Physical plant, food service
7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property
SUPERVISORS NAME: Mirella Quaranta
LICENSING EVALUATOR NAME: madeline bowman
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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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