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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440415
Report Date: 03/30/2022
Date Signed: 03/30/2022 05:00:08 PM


Document Has Been Signed on 03/30/2022 05:00 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:
03/30/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Daniel Villa, AdministratorTIME COMPLETED:
05:15 PM
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On 03/30/2022 at 2:55pm, Licensing Program Analysts (LPAs) C. Fowler and L. Hall arrived unannounced to conduct a proof of correction (POC) visit for the deficiencies cited on 3/22/2022.. LPAs met with Administrator, Daniel Villa and explained the purpose of the visit.

On today's date LPA observed ceiling had been repaired in the bathroom for CCR 87303(a) and garage no longer occupied staff using it as a sleeping room 87208(a)(7). These two (2) deficiency are cleared.

Administrator did not submit POC for 87621(b)(1)(B). A civil penalty has been assessed from 3/22/2022 to 3/30/2022 at $100 x 9 = $900.

LPAs printed out regulations 87621 and 87616 for Administrator to review and submit correct documents. Plan and proof of correction was discussed with Administrator.

Civil Penalties will continue to be assessed daily until corrected.

No deficiencies are being cited on this date.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
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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