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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201282
Report Date: 10/25/2023
Date Signed: 10/25/2023 12:18:05 PM

Document Has Been Signed on 10/25/2023 12:18 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:BUENAVISTA CARE @ BUTTERCUPFACILITY NUMBER:
079201282
ADMINISTRATOR:PEREZ, ROBERTOFACILITY TYPE:
735
ADDRESS:2814 BUTTERCUP CTTELEPHONE:
(925) 917-9640
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 4CENSUS: DATE:
10/25/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Roberto PerezTIME COMPLETED:
11:30 AM
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Facility Type: ARF
Application Type: Initial
Capacity: 4
Census (if any clients in care):
COMP II Participants: Roberto Perez, admin/licensee
Interview Method: Telephone interview

On October 25, 2023, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.
SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Dianne Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023
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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