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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800487
Report Date: 02/02/2021
Date Signed: 02/02/2021 04:42:29 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:AMEGIL HOME FOR THE ELDERLYFACILITY NUMBER:
361800487
ADMINISTRATOR:LUCAS, MARIAFACILITY TYPE:
740
ADDRESS:12410 BASSWOOD LANETELEPHONE:
(760) 221-3739
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY:4CENSUS: 0DATE:
02/02/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Juliet AguilarTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Christine Le conducted an announced case management televisit to the facility due to COVID-19. LPA met with facility staff Juliet Aguilar. The visit concluded with licensee Maria Lucas over the phone.

On 1/7/21, the Riverside Adult & Senior Care Regional Office received a notice from the licensee stating the intent to close the facility. The licensee requested to close the facility due to no longer being interested in maintaining a license. The licensee stated that there are currently no residents admitted to the facility and the last resident left on 2/2/21.

LPA toured the facility and observed that there are zero (0) residents in care. LPA requested for the facility staff to surrender the license and mail it to the Regional Office. LPA advised that the facility file will be closed upon return to the office.

The facility is closed as of today's date 2/2/21.

No deficiencies were cited during this visit. An exit interview was conducted where this report and closure letter were discussed and provided to the licensee via email. Report with facility representative signature was obtained.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Christine LeTELEPHONE: (951) 897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2021
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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