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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336401178
Report Date: 07/15/2022
Date Signed: 07/15/2022 03:22:45 PM


Document Has Been Signed on 07/15/2022 03:22 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:VILLA SAN JUAN BOARD & CARE FOR ELDERLYFACILITY NUMBER:
336401178
ADMINISTRATOR:SAN JUAN, TEODORA L.FACILITY TYPE:
740
ADDRESS:798 DE PASSE WAYTELEPHONE:
(951) 765-9202
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:6CENSUS: 0DATE:
07/15/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Teodora San Juan - Licensee/AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Crystal Colvin met with Licensee/Administrator Teodora San Juan at their other licensed facility (#336402944) in order to confirm that all residents from this facility have been relocated, as the Licensee forfeited their license to the Department via U.S. mail on 6/7/22. LPA Colvin met with Licensee/Administrator and went over the following information:
  • On 11/24/21 residents were provided with a 60-day notice of change of management/ownership.

  • On 1/24/22 the property was sold and escrow closed with agreement for new owner to apply for a license to operate the facility.

  • On 6/4/22, the new owner of the property (who had stated they were going to apply for a license of change of ownership to continue running the facility) informed Licensee/Administrator that they were withdrawing their license application and residents would need to be relocated.
  • The facility closed as of 6/8/22

  • The new owner moved in on 6/12/22.

  • Three residents (R1 - R3) were moved from the facility and placed at the Licensee/Administrator's neighboring facility (#336402944), where LPA Colvin was able to confirm their presence.

  • The fourth resident (R4) moved to Arizona. LPA Colvin was provided with address.

  • The fifth resident (R5) was moved out of the facility on 6/1/22 and relocated to West Hills Villa Gardens (#331881251)
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VILLA SAN JUAN BOARD & CARE FOR ELDERLY
FACILITY NUMBER: 336401178
VISIT DATE: 07/15/2022
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  • The facility R1 - R3 (#336402944) moved into only had two residents at the time they moved in, and has a capacity of six.


Prior to concluding the visit, LPA Colvin and a staff member at the new facility walked next door to this location for the purpose of attempting to gain entry to confirm that there are no residents remaining in care. LPA Colvin was able to speak with a resident at the location, though it was unclear if the location was now operating as a room and board or as a board and care without a license. LPA Colvin was denied entry by the resident and left the property. LPA Colvin observed a newly erected wooden fence separating the two properties. LPA Colvin was additionally provided with a contact number for the new property owner by the Licensee, but was unable to get a hold of them at this time. Further follow up may be warranted prior to closing the license.

LPA Colvin conducted an exit interview with Licensee/Administrator Teodora San Juan and a copy of this report was provided.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
LIC809 (FAS) - (06/04)
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