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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602645
Report Date: 08/29/2022
Date Signed: 08/29/2022 10:53:23 AM


Document Has Been Signed on 08/29/2022 10:53 AM - 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:BUENA CREEK RESIDENTIAL CAREFACILITY NUMBER:
374602645
ADMINISTRATOR:ILICH, VESNAFACILITY TYPE:
740
ADDRESS:3008 BUENA CREEK ROADTELEPHONE:
(760) 295-3630
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:6CENSUS: 0DATE:
08/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:ADMINISTRATOR, VESNA ILICHTIME COMPLETED:
10:55 AM
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On August 29, 2022, Licensing Program Analyst (LPA), Venus Mixson arrived at the above facility for an unannounced required annual with emphasis on infection control. LPA Mixson was greeted and granted entry by Administrator, Vesna Ilich. Upon arrival, Administrator indicated that she would like to close the facility.

The Administrator stated there are no residents residing in the facility and no staff employed since June 2022. LPA Mixson conducted the final walk through and verified that there are no residents present.

LPA Mixson later discussed closure practices and procedures with Administrator and obtained the license.

An exit interview was conducted and a copy of this report was provided to Administrator.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022
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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