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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703846
Report Date: 03/07/2022
Date Signed: 03/07/2022 03:28:36 PM


Document Has Been Signed on 03/07/2022 03:28 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:GRACE RESIDENTIAL CARE FACILITYFACILITY NUMBER:
421703846
ADMINISTRATOR:EVANGELINE P. AQUILIZAN 98FACILITY TYPE:
740
ADDRESS:515 EAST BUNNY AVENUETELEPHONE:
(805) 349-9410
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:6CENSUS: 0DATE:
03/07/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Evangeline Aquilizan, AdministratorTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Olson conducted a Case Management Closure visit to the facility above on 3/7/2022 at 3:20 PM. LPA met with licensee Evangeline Aquilizan and explained the purpose of the visit.

LPA toured the inside and outside of the facility. LPA observed no evidence of residents or staff on site, other than the licensee and her husband living on site. License has been surrendered to the department along with closure letter. The facility has not had any residents since 2018.

Exit interview conducted and copy of report emailed to Licensee.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2022
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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