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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800442
Report Date: 11/04/2021
Date Signed: 11/04/2021 12:34:27 PM

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:
11/04/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee, Roger BakerTIME COMPLETED:
12:00 PM
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An Informal Meeting was conducted today November 4, 2021 virtually via Microsoft Teams to discuss incident involving resident # 1(R1), and staff # 1(S1) occurring on September 28,2019. Present at today’s meeting were: Licensee, Roger Baker,Administrator, Douglass Baker,Co- Owner, Alex baker. Licensing Program Manager, Joel Esquivel, and Licensing Program Analyst, David Cuevas.

During today’s conference, the following matters were discussed:

(3) SUBSTANTIATED allegations, visit conducted on 02/04/2020 for:
  • Staff caused injury to resident.
  • Staff failed to respond to resident's medical needs in a timely manner.
  • Resident denied access to his walker.
  • Licensee, was offered to participate in Technical Support Program (TSP) during todays informal meeting that is offered through DSS.

Licensee, will consider participation into TSP program. During todays informal meeting Licensee, agreed to be in compliance to the items listed above and moving forward take the necessary precautions to avoid such occurrences.

An exit interview was conducted where this report was discussed and provided to the licensee. LPA emailed copy of the report for signature and requested the signed copy to be emailed back. Licensee agreed.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
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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