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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006128
Report Date: 09/01/2022
Date Signed: 09/01/2022 11:22:16 AM


Document Has Been Signed on 09/01/2022 11:22 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:VILLAS BY DOCTOR ROYAFACILITY NUMBER:
306006128
ADMINISTRATOR:JAFARI-HASSAD, ROYAFACILITY TYPE:
740
ADDRESS:23232 LA VACA STTELEPHONE:
(516) 322-3095
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 0DATE:
09/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Facility Administrator- Roya HassadTIME COMPLETED:
11:40 AM
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
Licensing Program Analyst (LPA) Celine De Perio conducted a continuation case management visit after concluding POC clearance with facility administrator (AD) Roya Hassad. LPA De Perio toured interior and exterior portion of the facility due to AD Hassad stating that she was inquiring about wanting to install a Hyperbaric Oxygen Treatment Chamber at facility. LPA De Perio verified that during today's visit, there were a total of 0 staff and 0 residents present. LPA De Perio explained to AD Hassad that per direction provided by Licensing Program Manager (LPM), AD Hassad will need to submit a formal email stating the purpose of the inquiry, plan of care, benefits, individuals it will serve, and who will be responsible. LPA De Perio also informed AD Hassad that the email request must be written in her own words and once received, will be elevated to Regional Manager (RM) for approval or denial.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
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 1