<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201323
Report Date: 06/06/2024
Date Signed: 06/06/2024 04:41:06 PM


Document Has Been Signed on 06/06/2024 04:41 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



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:
06/06/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Claro & Mylin Villanueva, LicenseeTIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 06/06/2024 at 2:10 PM, Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct a Pre-Licensing inspection. LPA met with Caregiver, Merna Sabas and explained the purpose of the visit. Merna phoned the pending Licensees, Claro & Mylin Villanueva to inform. The facility currently has six (6) residents.

LPA toured facility with Merna including but not limited to 5 bedrooms, 2 bathrooms, kitchen, garage, common areas and backyard. Bedrooms and living rooms were equipped with the proper furniture. Bathrooms were equipped with grab bars and non-skid mats. Linens and hygiene supplies were observed inside a cabinet. There is sufficient lighting throughout facility. Room temperature was maintained at 74 degrees F and hot water temperature was measured at 105 degrees F. First-aid kit was observed to be complete. Smoke detectors and carbon monoxide were operational. Fire extinguisher was purchased on 05/21/2024.

No issues noted during inspection. LPA observed that facility is ready to be licensed. This report will be submitted to the Central Applications Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3