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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201313
Report Date: 06/20/2024
Date Signed: 06/20/2024 10:01:51 AM


Document Has Been Signed on 06/20/2024 10:01 AM - 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:VILLA NUEVA CARE HOME 3FACILITY NUMBER:
079201313
ADMINISTRATOR:LARGOZA, SHIRLEYFACILITY TYPE:
740
ADDRESS:2560 CEDRO LANETELEPHONE:
(925) 300-3778
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 6DATE:
06/20/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mylin Villanueva, Applicant
Claro Villanueva, Applicant. 		TIME COMPLETED:
10:00 AM
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Component II completion: Successful

Facility Type: Residential Care Facility for the Elderly (RCFE)
Application Type: Change in Ownership (CHOW)
Capacity: 6
Census (if any clients in care): 6
COMP II Participants: Mylin Villanueva, Applicant
Claro Villanueva, Applicant.
Interview Method: Telephone interview

On June 20, 2024 at 9:00 AM, Applicants participated in COMP II. Identification of the applicants was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicants 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.

During COMP II, CAB analyst confirmed Applicant’s understanding of following areas:
1. Facility Operation: License type, client/resident populations, and program.
2. Admission Policies
3. Staffing Requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with applicants. Report sent via email and informed to return sign copy to CAB by end of business day.
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) 651-7817
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
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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