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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336403573
Report Date: 12/07/2020
Date Signed: 12/14/2020 08:38:53 AM

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:VILLAGE, THEFACILITY NUMBER:
336403573
ADMINISTRATOR:ROB TAKAMIFACILITY TYPE:
741
ADDRESS:2200 WEST ACACIATELEPHONE:
(951) 766-5116
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY:452CENSUS: 27DATE:
12/07/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Rob TakamiTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Stephanie Williams contacted the facility to conduct a case management visit via telephone due to the COVID-19 pandemic. LPA identified herself and discussed the purpose of the call with Administrator, Rob Takami.

LPA discussed with the Administrator that the purpose of the case management visit is to confirm an individual with a non-exemptible conviction is not present or working in the facility. Based on evidence obtained during today's visit, the LPA has verified the individual is not present, employed, or residing at the facility. The individual named in the Confirmation of Removal Letter dated 11/6/2020 is Kim Gallegos. During the visit, the LPA reviewed the facility's staff roster to verify that the individual is not working at the facility. The Administrator filled out the Confirmation of Removal form to confirm that Gallegos is not working in the facility.

Verification of removal is complete. An exit interview was conducted via telephone where this report (LIC 809) was discussed and a copy was provided to Takami via email.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie WilliamsTELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2020
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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