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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201323
Report Date: 05/10/2024
Date Signed: 05/10/2024 11:49:16 AM


Document Has Been Signed on 05/10/2024 11:49 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
CENTRALIZED APP UNIT, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:VILLA NUEVA CARE HOME 4FACILITY NUMBER:
079201323
ADMINISTRATOR:VILLANUEVA, MYLIN PFACILITY TYPE:
740
ADDRESS:58 MIDHILL RDTELEPHONE:
(510) 512-4368
CITY:MARTINEZSTATE: CAZIP CODE:
94553
CAPACITY:6CENSUS: 6DATE:
05/10/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mylin VillanuevaTIME COMPLETED:
11:28 AM
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Facility Type: RCFE
Application Type: CHOW
Capacity: 6
Census (if any clients in care): 6
COMP II Participants: Mylin Villanueva (Corporate Board Member/Administrator)
Interview Method: Telephone interview


On May 10, 2024, applicant(s)/administrator participated in COMP II for the below pending facilities: [list out all of the applicable pending applications in the following format: Villa Nueva Care Home 4/079201323, Villa Nueva Care Home 5/079201326. Identification of the applicant(s) and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant(s) 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.

During COMP II, CAB analyst confirmed Applicant/Administrator’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
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) 651-7817
LICENSING EVALUATOR NAME: Diamond LawTELEPHONE: (916) 657-3571
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2024
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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