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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530032
Report Date: 02/13/2023
Date Signed: 02/13/2023 10:26:45 AM


Document Has Been Signed on 02/13/2023 10:26 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
, CA 92507



FACILITY NAME:VILLA DE ANZAFACILITY NUMBER:
335530032
ADMINISTRATOR:PENDINGFACILITY TYPE:
740
ADDRESS:5881 EL PALOMINO DRIVETELEPHONE:
(951) 683-3333
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:197CENSUS: 93DATE:
02/13/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Eecutive Director Katherine TrevinoTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 02/13/2023 at 09:35 AM, unannounced for a collateral visit on a complaint investigation to obtain Resident #1 (R1) facility records in reference to complaint control number 18-AS-20211223155629. During this visit LPA Brown was met by facility Executive Director Katherine Trevino.

An exit interview was conducted and a copy of this report (LIC809) was discussed and provided to Executive Director Katherine Trevino.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2023
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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