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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336405651
Report Date: 07/18/2022
Date Signed: 07/18/2022 03:53:34 PM

Document Has Been Signed on 07/18/2022 03:53 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 ANNEFACILITY NUMBER:
336405651
ADMINISTRATOR:FE MAESTRADOFACILITY TYPE:
740
ADDRESS:3011 NOVA SCOTIATELEPHONE:
(951) 784-1066
CITY:RIVERSIDESTATE: CAZIP CODE:
92506
CAPACITY: 6CENSUS: 5DATE:
07/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:ADMINISTRATOR FE MAESTRADOTIME COMPLETED:
03:53 PM
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On 07/18/2022, Licensing Program Analyst (LPA), Venus Mixson arrived at the above facility to obtain perennate document. The document was obtained.

An exit interview was conducted and a copy of this report was given to Administrator.





SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2022
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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