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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 134604316
Report Date: 08/19/2021
Date Signed: 08/20/2021 08:38:30 AM

Document Has Been Signed on 08/20/2021 08:38 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:VILLA NAYARITFACILITY NUMBER:
134604316
ADMINISTRATOR:RAMIREZ FERNANDEZ,GFACILITY TYPE:
735
ADDRESS:412 S C STTELEPHONE:
(442) 270-6587
CITY:IMPERIALSTATE: CAZIP CODE:
92251
CAPACITY: 4CENSUS: 4DATE:
08/19/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:Administrator, Guillermo Ramirez FernandezTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA), Kristina Ryan, conducted an unannounced case management visit. LPA was granted entry by Caregiver, Alonso Felix and met with Administrator, Guillermo Ramirez Fernandez. LPA was granted entry after identifying herself and disclosing the purpose of the visit.

Today's visit was in response to a series of self-reported incidents regarding Client 1, (C1).

On today’s date, LPA toured the facility, performed a health and welfare check, requested copies of facility records, and interviewed clients and staff. No deficiencies were cited at this time.

An exit interview was conducted with Mr. Fernandez, to whom a copy of this report, LIC 811 Confidential Names list, and the Licensee/Appeal Rights (9058 01/16) were provided via e-mail. An electronic read receipt verifies receipt of these documents.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Kristina Ryan
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2021
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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