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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600012
Report Date: 11/09/2022
Date Signed: 11/09/2022 12:08:47 PM


Document Has Been Signed on 11/09/2022 12:08 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:WILLOW GLEN RESIDENCEFACILITY NUMBER:
075600012
ADMINISTRATOR:VILLAREAL, LEVIFACILITY TYPE:
740
ADDRESS:2040 MENDOCINO DRIVETELEPHONE:
(925) 458-5057
CITY:BAY POINTSTATE: CAZIP CODE:
94565
CAPACITY:5CENSUS: 1DATE:
11/09/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Levi Villareal, licenseeTIME COMPLETED:
12:10 PM
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On 11/09/2022 at 10:55AM, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Licensee, Levi Villareal and explain the purpose of the visit.

LPA visited the facility on 8/3/2022 and observed that the facility did not have a qualified Administrator employed. LPA cited and assessed ongoing civil penalties under section 87405(a) Administrator – Qualifications and Duties. Licensee was given a plan of correction date. Licensee telephone LPA on 9/19/2022 to request an extension for the plan of correction which LPA granted until 10/17/2022. LPA conducted another visit on 10/19/2022 and gave a new POC date of 10/26/2022. On today’s date Licensee have not hired an Administrator or have not recertified as the Administrator.

A civil penalty of $1400.00 will be assessed on today’s date from 10/27/2022 to 11/09/2022. Facility is subject to ongoing civil penalties of $100.00 per day until the deficiency is corrected.

Exit interview conducted. A copy of this report, LIC421FC, and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
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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