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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201326
Report Date: 06/19/2024
Date Signed: 06/19/2024 10:45:55 AM


Document Has Been Signed on 06/19/2024 10:45 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:VILLA NUEVA CARE HOME 5FACILITY NUMBER:
079201326
ADMINISTRATOR:VILLANUEVA, MYLINFACILITY TYPE:
740
ADDRESS:4369 ROSE LANETELEPHONE:
(925) 791-0290
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 0DATE:
06/19/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Mylin Villanueva, Licnesee TIME COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Jill Clancy-Czuleger, conducted an announced pre-licensing inspection. License application is for (6) total capacity, of which 6 maybe non-ambulatory. Fire clearance was granted on April 04,2024. LPA met with Mylin Villanueva (applicant-administrator) and Claro Villanueva (applicant-licensee).

LPA inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade.

Fire extinguishers were observed fully charge and tags showed they were purchased on 12/28/2023. The two-in-one carbon monoxide and smoke detector tested and observed functional.


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SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 5
FACILITY NUMBER: 079201326
VISIT DATE: 06/19/2024
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LPAs observed the following:
First aid kit did not have a thermometer or manual.
Hot water temperature in one of the bathrooms tested and measured at 103.8. degrees Fahrenheit.
Beds did not have sheets or mattress protectors
Equipment and supplies for residents' personal hygiene are available and on site.

Upon receipt of proof of corrections for the items above, by June 28, 2024 LPA J. Clancy-Czuleger will inform CAB. Issuance of license is pending upon final review by CAB analyst.

Exit interview conducted and copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC809 (FAS) - (06/04)
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