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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850214
Report Date: 01/25/2022
Date Signed: 01/26/2022 04:43:35 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:
425850214
ADMINISTRATOR:RUST, JESSICAFACILITY TYPE:
740
ADDRESS:938 WEST BUNNY AVENUETELEPHONE:
(805) 928-5654
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY:6CENSUS: 6DATE:
01/25/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:26 PM
MET WITH:Jessica RustTIME COMPLETED:
04:45 PM
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 Analysts (LPA) Diaz conducted a pre-licensing visit to the facility above at 1:26pm. LPA met with Administrators, Jessica Rust, and Jennifer Villaros. The applicant has obtained fire clearance for (5) non-ambulatory and (1) bedridden residents, for a total capacity of six (6) Residents.

Beginning at 1:30pm, LPA inspected the proposed facility for Fire Safety, Personal Accommodations, and Food Service. All hard-wired smoke alarms were functioning properly at this time. The carbon monoxide detector was functioning. LPA observed one fire extinguisher to be fully charged. Paint, windows, blinds, and floors are in good repair. There are no firearms on the premises. The common living and dining areas are clean and properly furnished. A working telephone is present. The facility has a comfortable temperature.

The proposed facility has 5 resident bedrooms total. 5 resident bedrooms were furnished and contained beds, chairs, bedside tables and lamps. All beds have sheets, pillows, and mattress pads. There is also an ample supply of linens and towels. The proposed facility has (2) full bathrooms for resident use. LPA observed 5 night-light present in the main hallway. Hot water measured at 108.8 and 113 degrees Fahrenheit. The kitchen contained a sufficient supply of dishes, glasses and utensils. A seven-day supply of non-perishable food is present, and facility has flash lights and batteries. A locked medication cabinet and First Aid Kit was observed to be complete. There is space to lock chemicals in the garage, under the bathroom sink and under the kitchen sink. Sharp items are stored in a locked kitchen drawer. The laundry room is located in the garage and supplies will be stored in the locked garage cabinets. The building and grounds are free from hazard

The report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted and report issued.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien DiazTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2022
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