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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880905
Report Date: 03/29/2022
Date Signed: 03/29/2022 03:40:10 PM


Document Has Been Signed on 03/29/2022 03:40 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: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:
03/29/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Azizi Baranauskas - Executive Director (ED)TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Crystal Colvin conducted an unannounced visit to the facility to follow up on a confirmation of removal of S1. LPA Colvin met with Executive Director Azizi Baranauskas and discussed the purpose of today's inspection.

The Criminal Record Exemption needed notification letter dated 2/17/22 was generated to notify the licensee that S1 must not work or be present in the facility licensed by the Department unless a Criminal Record Exemption is granted. LPA Colvin discussed the confirmation of removal notice with Azizi Baranauskas. LPA Colvin was informed that S1 was removed from the facility on 3/2/22. Azizi Baranauskas stated she understands that S1 cannot work, reside or be present in a facility licensed by the Department unless a Criminal Record Exemption is granted. During this visit, LPA Colvin reviewed the submitted paperwork for the Confirmation of Removal for S1 with Azizi Baranauskasm and confirmed that the mentioned staff person does not work, reside nor is present in any licensed facility.

Based on evidence obtained during today’s visit, LPA Colvin has verified the individual is not present, employed or residing at the facility. Azizi Baranauskas provided LPA with a staff schedule for the month of March 2022, which indicated that S1 is not scheduled to work for the entire month.

An exit interview was conducted, and a copy of this report was provided to Executive Director Azizi Baranauskas.

Verification of removal is complete.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
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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