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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 03:59:11 PM


Document Has Been Signed on 07/23/2024 03:59 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Claro Villanueva, Licensee/Applicant
"Lito" Paquito Balbuena, Caregiver		TIME COMPLETED:
03:00 PM
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On 7/23/2024 at 2:00PM, Licensing Program Analyst (LPA) G. Luk conducted a face to face Component III presentation. LPA met with Licensee/Applicant, Claro Villanueva. Licensee/Applicant was unable to stay to sign the reports and designated caregiver, "Lito" Paquito Balbuena to sign the reports.

LPA presented Component III power point and discussed the regulations embodied in the presentation. LPA observed Licensee/Applicant gained knowledge about running and maintaining the facility in accordance with Title 22 regulations.

LPA concluded Component III.

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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