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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201243
Report Date: 07/17/2023
Date Signed: 07/17/2023 06:01:27 PM


Document Has Been Signed on 07/17/2023 06:01 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:VILLA NUEVA CARE HOME 1FACILITY NUMBER:
079201243
ADMINISTRATOR:PERDIGUERRA, MYLINFACILITY TYPE:
740
ADDRESS:2130 DORSCH ROADTELEPHONE:
(510) 512-4368
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 5DATE:
07/17/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Fe DimaanoTIME COMPLETED:
06:30 PM
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On 07/17/2023 at 03:00 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced for this pre-licensing inspection. LPA informed Administrator (ADM) Fe Dimaano of the purpose of the visit.

LPA and Administrator toured facility inside and outside.

Pre-Licensing is complete and this facility has no deficiencies.

Exit interview conducted with ADM. A copy of this report provided for ADM by LPA via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2023
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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