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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880645
Report Date: 05/20/2022
Date Signed: 05/20/2022 02:30:22 PM


Document Has Been Signed on 05/20/2022 02:30 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:BELLA VILLAGGIOFACILITY NUMBER:
331880645
ADMINISTRATOR:JIM GERMYNFACILITY TYPE:
740
ADDRESS:40235 PORTOLA AVETELEPHONE:
(760) 607-5200
CITY:PALM DESERTSTATE: CAZIP CODE:
92260
CAPACITY:170CENSUS: 137DATE:
05/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Roxanne CerrascoTIME COMPLETED:
11:45 AM
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LIcensing Program Analyst (LPA) conducted an unannounced case management visit to make an amendment to complaint control number 18-AS-20200629105748. LPA met with Health and Wellness Roxanne Cerrasco..

LPA and Ms. Cerrasco discussed the amendment make to the complaint and a copy of that amendment and this case management document ws given to Ms. Cerrasco.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Jennifer SeminTELEPHONE: (951) 473-7024
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
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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