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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880905
Report Date: 03/04/2022
Date Signed: 03/04/2022 10:50:16 AM


Document Has Been Signed on 03/04/2022 10:50 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, 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: 36DATE:
03/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Azizi Baranauskas, Executive Director (ED)TIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA), Stephanie Torres, made an unannounced visit to the facility to conduct a health and safety visit in relation to complaint #18-AS-20220303140300. The LPA met with Executive Director (ED), Azizi Baranauskas and informed her of the purpose of the visit.

On this visit the LPA conducted staff and resident interviews, reviewed records and took copies of pertinent information. No health and safety concerns were observed at this time.

This report was reviewed with Baranauskas and a copy was provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie TorresTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
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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