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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201323
Report Date: 06/06/2024
Date Signed: 06/06/2024 07:38:45 PM


Document Has Been Signed on 06/06/2024 07:38 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
07:00 PM
MET WITH:Mylin Villanueva, Licensee/AdministratorTIME COMPLETED:
07:30 PM
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On 06/06/2024 at 7:00 PM, Licensing Program Analyst (LPA) Lori Alexander conducted a face to face Component III presentation on starting at 7:00PM. LPA conducted Component III with Licensee/Administrator, Mylin Villanueva.

LPA presented Component III power point and discussed the regulations embodied in the power point. LPA observed participants gained knowledge about running and maintaining the facility in accordance with regulations.

Exit interview conducted and a copy of 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)
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