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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880905
Report Date: 07/29/2024
Date Signed: 07/29/2024 12:02:25 PM


Document Has Been Signed on 07/29/2024 12:02 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:TEMECULA MEMORY CAREFACILITY NUMBER:
331880905
ADMINISTRATOR:GEDDIE, JAMESFACILITY TYPE:
740
ADDRESS:44320 CAMPANULA WAYTELEPHONE:
(951) 428-4990
CITY:TEMECULASTATE: CAZIP CODE:
92592
CAPACITY:64CENSUS: 0DATE:
07/29/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Azizi Baranauskas - Clinical Care CoordinatorTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Sara Martinez made an unannounced case management visit regarding pending closure of the facility. LPA met with Clinical Care Coordinator Azizi Baranauskas and explained the purpose of the visit.

During today's visit, LPA toured the facility, and observed no staff, no residents in care, and no resident's belongings. The last day facility had residents in care was on 06/15/2024. Baranauskas informed LPA all residents were relocated due to pending closure. Baranauskas provided LPA the names of the former residents, the facility name and address the residents were relocated to, and the names of the residents' responsible party and contact information.


Due to pending closure, License was not obtained at this time. A follow-up visit for the facility closure will be conducted.

An exit interview was conducted and a copy of this report was provided, to Azizi Baranauskas.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2024
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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