<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800193
Report Date: 10/16/2024
Date Signed: 10/17/2024 04:40:52 PM


Document Has Been Signed on 10/17/2024 04:40 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:HILLSIDE VILLA RETIREMENT HOME #2FACILITY NUMBER:
405800193
ADMINISTRATOR:CONNIE K. RAY 98FACILITY TYPE:
740
ADDRESS:533 LE POINT STREETTELEPHONE:
(805) 481-8384
CITY:ARROYO GRANDESTATE: CAZIP CODE:
93420
CAPACITY:6CENSUS: 0DATE:
10/16/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:TIME COMPLETED:
08:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) De Leon conducted a Case Management Closure visit the the facility above.

LPA walked around the house and was able to look thorough all windows the house is completely empty and remodel construction is currently being done.

The business was officially closed on 09/01/2024 when the remaining residents were placed and staff was no longer needed. The home was listed for sale and was sold, escrow closed on 10/11/2024.

Licensee followed all requirements for closure, 60-day letters were sent to residents and all residents were relocated.

The facility is officially closed and no longer in business as of 09/01/2024.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
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 1