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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602769
Report Date: 11/15/2023
Date Signed: 11/15/2023 12:41:33 PM


Document Has Been Signed on 11/15/2023 12:41 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:BELLEVUE VILLAFACILITY NUMBER:
374602769
ADMINISTRATOR:CAROLINA S DIZONFACILITY TYPE:
740
ADDRESS:2080 HEIGHTS COURTTELEPHONE:
(760) 518-8508
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY:6CENSUS: 5DATE:
11/15/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Licensee, Carolina S Dizon TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to the facility to conduct a case management visit on the health, safety, and welfare of residents in care due to change of ownership. LPA met with Licensee, Carolina Dizon. LPA was informed that five (5) residents currently reside at this facility. There were two (2) staff members on duty, during the time of the visit.

LPA toured the facility and observed all facility utilities to be on and operating without issue, food supply is sufficient, there is no immediate concern for residents in care.

Based on the information obtained during today’s visit, there are no deficiencies or civil penalties being cited per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted with Licensee, Carolina Dizon and a copy of this report is left with the Licensee, as evidence by her signature.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen BanrasavongTELEPHONE: 951-248-0319
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2023
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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