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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530032
Report Date: 07/26/2022
Date Signed: 07/26/2022 02:13:39 PM


Document Has Been Signed on 07/26/2022 02:13 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, 744 P STREET, MS 9-14-8201
, CA 95814



FACILITY NAME:VILLA DE ANZAFACILITY NUMBER:
335530032
ADMINISTRATOR:ESPINAL, KENNYFACILITY TYPE:
740
ADDRESS:5881 EL PALOMINO DRIVETELEPHONE:
(951) 683-3333
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:197CENSUS: DATE:
07/26/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:TIME COMPLETED:
02:13 PM
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COMP II by CAB successfully completed

Facility Type: RCFE
Application Type: CHOW
Capacity: 197
Census (if any clients in care): 91
Method: Telephone call with CAB
COMP II Participants: Adam Zenou, CEO/Owner; Kenny Espinal, Administrator; Shannon Betker, analyst.
Applicant/administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming driver’s license number. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Staff qualifications and responsibilities
3. Staff training
4. Applicant and Administrator qualifications
5. Grievances, Complaints, Community resources
6. Food service
7. Medication management
8. Application document review and technical assistance: Pre-licensing inspection
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) 651-7817
LICENSING EVALUATOR NAME: Shannon BetkerTELEPHONE: (916) 651-3018
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
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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