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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336402944
Report Date: 10/27/2023
Date Signed: 10/27/2023 01:25:10 PM


Document Has Been Signed on 10/27/2023 01:25 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:VILLA SAN JUAN BOARD & CARE FOR THE ELDERLY #2FACILITY NUMBER:
336402944
ADMINISTRATOR:TEODORA L. SAN JUANFACILITY TYPE:
740
ADDRESS:786 DE PASSE WAYTELEPHONE:
(951) 765-9202
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:6CENSUS: 6DATE:
10/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:52 PM
MET WITH:Teodora San Juan, AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to deliver findings to a complaint in reference to a closed facility that was related to this facility's Licensee. See 18-AS-20220121170708 for further information.

LPA met with Licensee/Administrator Teodora San Juan and toured the facility. Findings were delivered in reference to the aforementioned complaint number.

An exit interview was conducted where a copy of this report was discussed with and provided.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
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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