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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006128
Report Date: 03/30/2023
Date Signed: 03/30/2023 03:56:15 PM


Document Has Been Signed on 03/30/2023 03:56 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
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:
03/30/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Facility Administor - Roya Jafari HassadTIME COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to the facility to conduct a health and safety check in conjunction for compliant: 22-AS-20230330082748.

LPA conducted a walk-through of the exterior portion of the facility and observed the facility to be empty during this time.

LPA contacted facility administrator (AD) Roya Jafari Hassad via phone call, of which AD was unable to be present during time of visit.

LPA conducted an exit interview with AD via phone call, and a copy of this report was provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023
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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