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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602769
Report Date: 10/24/2024
Date Signed: 10/24/2024 11:59:38 AM

Document Has Been Signed on 10/24/2024 11:59 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BELLEVUE VILLAFACILITY NUMBER:
374602769
ADMINISTRATOR/
DIRECTOR:		CAROLINA S DIZONFACILITY TYPE:
740
ADDRESS:2080 HEIGHTS COURTTELEPHONE:
(760) 294-8086
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 6CENSUS: 4DATE:
10/24/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Licensee, Carolina DizonTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Janira Arreola and Regional Manager (RM) Reyna Lacey conducted a virtual office visit with the licensee, Carolina Dizon along with representatives from Centralized Applications Bureau (CAB).

The purpose of the office meeting was in regards to a deficiency issued on 12/13/23 for Regulation Section 87205(b) Accountability of Licensee Governing Body. The deficiency was issued due to an inactive governing body, Allied Care LLC. The agreed upon plan of correction was for the licensee to submit an application to CAB. The correction was met when it was confirmed the application was submitted 1/3/2024.

During today's meeting, CAB representative confirmed an approved fire clearance was received on 10/23/2024. The following items were discussed as outstanding for the application of the new license:

· Bank statements for the facility

· CPR and first aid training

· Liability Insurance

· LIC401 Monthly Operating Statement

· Admission Agreement

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BELLEVUE VILLA
FACILITY NUMBER: 374602769
VISIT DATE: 10/24/2024
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The licensee, Carolina Dizon agreed to submit the CPR certificate, liability insurance, LIC401 Monthly Operating Statement, and admission agreement to CAB by 5pm today. The licensee, Carolina Dizon agreed to contact CAB by 10/25/2024 to provide status of bank statement.

The licensee, Carolina Dizon was advised to keep in contact with CAB on the process of their application, and to conduct the outstanding tasks for the application in a timely manner. The licensee was advised that if all the above items are not submitted the department may deny the application.

An exit interview was conducted with Licensee, Carolina Dizon over the phone where this report was reviewed and emailed.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC809 (FAS) - (06/04)
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