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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850301
Report Date: 11/16/2022
Date Signed: 11/16/2022 03:33:15 PM

Document Has Been Signed on 11/16/2022 03:33 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: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: 0DATE:
11/16/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Helen Rose Busch & Johnna UddenTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) KaSandra Lopez conducted a subsequent pre-licensing visit to the above noted facility to follow up on corrections identified during the initial pre-licensing visit on 11/04/2022. The LPA met with applicants Helen Rose Busch and Johnna Udden.

Since the initial inspection, the applicants submitted an updated facility sketch indicating bedroom #6 will now be a common activity room and bedroom #3 will be a resident room single occupancy. The total occupancy of six (6) residents remains the same. Residents will now have access to the backyard through the common activity room.

The LPA conducted a physical plant tour of the facility. The LPA observed safety modifications on the knobs of the kitchen stove, two portable closets in bedroom #1 which are secured to the wall, and two self latching gates in the backyard.


Pre-Licensing deficiencies have been resolved. Pre-Licensing is now complete.
This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2022
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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