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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201313
Report Date: 07/23/2024
Date Signed: 07/23/2024 03:58:41 PM


Document Has Been Signed on 07/23/2024 03:58 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 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:
07/23/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Claro Villanueva, Licensee/Applicant
"Lito" Paquito Balbuena, Caregiver		TIME COMPLETED:
02:00 PM
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On 7/23/2024 at 10:15AM, Licensing Program Analyst (LPA) G. Luk conducted a Pre-licensing Inspection. LPA met with caregiver, "Lito" Paquito Balbuena and explained the purpose of the visit. Licensee/Applicant, Claro Villanueva arrived an hour later. Licensee/Applicant was unable to stay to sign the reports and designated caregiver, "Lito" Paquito Balbuena to sign the reports.


LPA toured facility including but not limited to resident's bedrooms, bathrooms, common areas, dining area, kitchen, garage, and outdoor area. LPA observed lighting in all rooms. LPA observed facility has one week of non-perishable and two days of perishable food supplies available. Smoke and carbon monoxide detectors were observed. First aid kit was complete. Emergency disaster plan was complete. Fire extinguishers were observed to be full and was purchased on 5/17/2024. Hot water was measured at 120 degrees F in the hallway bathroom.

The following will need to be completed before recommending licensure to Centralized Application Bureau (CAB):

1. LPA observed CCLD complaint poster size is 8.5" by 11" and regulation requirement is 20" by 26".

Licensee/Applicant will submit proof of corrections to CCLD on/before 7/30/2024.


Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
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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