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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800442
Report Date: 09/30/2021
Date Signed: 09/30/2021 11:33:18 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:VILLA LIVINGFACILITY NUMBER:
361800442
ADMINISTRATOR:BAKER, DOUGLASFACILITY TYPE:
740
ADDRESS:9377 VALLEY VIEW STREETTELEPHONE:
(909) 727-3663
CITY:RANCHO CUCAMONGASTATE: CAZIP CODE:
91737
CAPACITY:6CENSUS: 6DATE:
09/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Licensee, TIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) David Cuevas met with Licensee, Roger Baker for the purpose of amending report for complaint report (18-AS-20190930141601). LPA Cuevas went over the amended report with Licensee, Roger Baker and provided copies of both the amended complaint report as well as this report.

An exit interview was conducted and a copy of all reports was provided to Licensee, Roger Baker.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
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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