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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850027
Report Date: 06/24/2021
Date Signed: 06/25/2021 03:05:11 PM

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:VILLA CARE HOME IFACILITY NUMBER:
425850027
ADMINISTRATOR:VILLAROS, JENNIFERFACILITY TYPE:
740
ADDRESS:938 WEST BUNNY AVENUETELEPHONE:
(805) 928-5654
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY:6CENSUS: 6DATE:
06/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jennifer Villaros, LicenseeTIME COMPLETED:
04:30 PM
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On 6/24/21, at 03:00 PM, Licensing Program Analyst (LPA) Toan Luong conducted an unannounced onsite one year infectious control annual visit to the facility. LPA met with Licensee Jennifer Villaros. LPA explained the purpose of the visit.

Licensee took LPA on a physical plant tour of the facility. The facility has submitted an approved mitigation plan to the department.

The facility is a Residential Care Facility for the Elderly. During the facility tour, LPA advised newly received CAL/OSHA's Safety and Health Protection signage should have emergency contact information completed.

LPA reviewed the Annual Mitigation Inspection Control Tool Module. Module was addressed with Licensee to satisfaction.

Exit interview was conducted. No deficiencies were cited. Report was emailed to Licensee.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
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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