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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440415
Report Date: 03/01/2022
Date Signed: 03/01/2022 06:16:43 PM


Document Has Been Signed on 03/01/2022 06:16 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:VILLA BOARD AND CARE HOMEFACILITY NUMBER:
071440415
ADMINISTRATOR:VILLA, DANIEL D.FACILITY TYPE:
740
ADDRESS:831 CORAL DR.TELEPHONE:
(510) 799-5572
CITY:RODEOSTATE: CAZIP CODE:
94572
CAPACITY:6CENSUS: 1DATE:
03/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Daniel Villa, AdministratorTIME COMPLETED:
06:20 PM
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On 03/01/2022 at 2:30pm Licensing Program Analysts (LPAs) C. Fowler and L. Hall arrived unannounced to conduct Infection Control Inspection. LPAs met with Administrator, Daniel Villa and explained the purpose of the visit.

Upon entry, LPAs temperature was not checked. LPA observed screening station that contained hand sanitizer and thermometer . LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. LPA observed cough etiquette and physical distancing posted in the common areas. Smoke detector/carbon monoxide was in operation condition. First aid kit was complete.

LPAs will return and continue the infection control inspection at a later date.

Exit interview conducted and a copy of this report provided.

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SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022
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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