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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421700411
Report Date: 12/20/2022
Date Signed: 12/20/2022 10:20:21 AM


Document Has Been Signed on 12/20/2022 10:20 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:VALLE VERDEFACILITY NUMBER:
421700411
ADMINISTRATOR:SUSAN E PONCEFACILITY TYPE:
741
ADDRESS:900 CALLE DE LOS AMIGOSTELEPHONE:
(805) 883-4193
CITY:SANTA BARBARASTATE: CAZIP CODE:
93105
CAPACITY:547CENSUS: 366DATE:
12/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Susie Ponce, Administrator and Adam Kopras, Assisted Living ManagerTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Olson conducted a case management visit to check on the status of Resident 1 (R1), after R1 recently relocated to this facility. LPA met with Susie Ponce, Administrator and Adam Kopras, Assisted Living Manager and explained the purpose of the visit. LPA toured the facility and met with R1 in R1’s room. LPA interviewed R1 about their experience at the facility. R1 confirmed all their needs were met by the facility and had no concerns.

Exit interview, report given via email.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022
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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