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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802288
Report Date: 06/20/2023
Date Signed: 06/20/2023 11:41:16 AM


Document Has Been Signed on 06/20/2023 11:41 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:PARADISE VALLEY CAREFACILITY NUMBER:
405802288
ADMINISTRATOR:CAROLA WHITEFACILITY TYPE:
740
ADDRESS:9525 GALLINA CTTELEPHONE:
(805) 468-4141
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:15CENSUS: 5DATE:
06/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rocio Tavarez, Med-Tech/Staff SupervisorTIME COMPLETED:
11:55 AM
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On 6/20/23 at 10:00 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced Case Management visit. LPA met with Rocio Tavarez, Med-Tech/Staff Supervisor, and explained the reason for the visit.

CCL learned the facility was closing and conducted a visit to check on the residents. LPA toured the facility, interviewed a resident, and obtained relevant documents.

Exit interview conducted, report given.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
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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