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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360909246
Report Date: 11/16/2022
Date Signed: 11/16/2022 01:42:37 PM

Document Has Been Signed on 11/16/2022 01:42 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
, CA 92507
FACILITY NAME:PADUA VILLAGE, INC.FACILITY NUMBER:
360909246
ADMINISTRATOR:KIMBERLY ROWEFACILITY TYPE:
735
ADDRESS:11981 MIDWAY RD.TELEPHONE:
(760) 248-6245
CITY:LUCERNE VALLEYSTATE: CAZIP CODE:
92356
CAPACITY: 26CENSUS: DATE:
11/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:53 PM
MET WITH:Shawn Barracks, Program DirectorTIME COMPLETED:
01:46 PM
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On 11/16/2022, at 12:53 p.m., Licensing Program Analyst (LPA) Rayshaun Nickolas made an unannounced visit to the facility to obtain signatures on an amended LIC 9099. LPA met with Program Director Shawn Barracks and explained the purpose of the visit.

An exit interview was conducted and a copy of this report and amended LIC 9099 were provided to Barracks.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2022
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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