430708498-5-5-2021-26-AS-SYIP-C2RQ5D-20210506115146

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430708498
Report Date: 05/05/2021
Date Signed: 05/05/2021 02:36:13 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/09/2021 and conducted by Evaluator Yatfai Ng

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20210409104525

FACILITY NAME:	VILLA-MAR RESIDENTIAL CARE HOME		FACILITY NUMBER:	430708498
ADMINISTRATOR:	SAMPANI, MARINA		FACILITY TYPE:	740
ADDRESS:	333 LASTRETO AVENUE		TELEPHONE:	(408) 730-8632
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94085
CAPACITY:	6	CENSUS: 2	DATE:	05/05/2021
		UNANNOUNCED	TIME BEGAN:	10:27 AM
MET WITH:	Marina Sampani		TIME COMPLETED:	10:49 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff do not provide activities for the residents.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Yatfai Eric Ng conducted a subsequent unannounced investigation tele-visit. Due to current COVID-19 situation, LPA virtually met with the Licensee Marina Sampani.

On 04/14/2021, an initial unannounced investigation was conducted by LPA. LPA toured the facility, interviewed 2 residents, 2 staff, and 1 visitor.

On 04/14/2021, LPA interviewed 2 residents. 2 out of 2 residents stated they were not provided activity in the facility.

On 04/14/2021, LPA interviewed 2 staff. 2 out of 2 staff stated there was no activity provided to the residents.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 26-AS-20210409104525

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: VILLA-MAR RESIDENTIAL CARE HOME	FACILITY NUMBER: 430708498
	VISIT DATE: 05/05/2021

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
26
27
28
29
30
31
32

On 04/14/2021, LPA interviewed 1 visitor. 1 out of 1 visitor stated there was no activity provided to the residents with visitor’s observation.

On 04/14/2021, LPA did not observe any activity provided to the residents during visit.

Based on interviews and observation, the preponderance of evidence standard has been met; therefore, the allegation is found to be SUBSTANTIATED, which means that the allegation did occur.

A deficiency was cited today as per California Code of Regulations, Title 22. See 9099-D for more information.

This report was reviewed with Licensee. A copy of this report was emailed for signature. A copy of appeal rights was also emailed for reference.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/09/2021 and conducted by Evaluator Yatfai Ng

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20210409104525

FACILITY NAME:	VILLA-MAR RESIDENTIAL CARE HOME		FACILITY NUMBER:	430708498
ADMINISTRATOR:	SAMPANI, MARINA		FACILITY TYPE:	740
ADDRESS:	333 LASTRETO AVENUE		TELEPHONE:	(408) 730-8632
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94085
CAPACITY:	6	CENSUS: 2	DATE:	05/05/2021
		UNANNOUNCED	TIME BEGAN:	10:27 AM
MET WITH:	Marina Sampani		TIME COMPLETED:	10:49 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff left resident(s) unsupervised.
Resident(s) showering needs are not being met.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Yatfai Eric Ng conducted a subsequent unannounced investigation tele-visit. Due to current COVID-19 situation, LPA virtually met with the Licensee Marina Sampani.

On 04/14/2021, an initial unannounced site visit was conducted by LPA. LPA toured the facility, interviewed 2 residents, 2 staff, and 1 visitor.

On 04/14/2021, LPA interviewed 2 residents. 2 out of 2 residents stated they were not left unsupervised in the facility and that there was always at least one staff. 2 out of 2 residents stated the staff helped and offered to help them with showering.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 26-AS-20210409104525

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: VILLA-MAR RESIDENTIAL CARE HOME	FACILITY NUMBER: 430708498
	VISIT DATE: 05/05/2021

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
26
27
28
29
30
31
32

On 04/14/2021, LPA interviewed 2 staff. 2 out of 2 staff stated they never left residents unsupervised and that there was always at least 1 person in the facility. 2 out of 2 staff stated that they helped the residents to shower or offered help, but residents sometimes refused.

On 04/14/2021, LPA interviewed 1 visitor. 1 out of 1 visitor stated there was always at least 1 staff whenever the visitor visited. 1 out of 1 visitor stated seeing staff helping residents to shower. No foul smell or odor from residents as far as the visitor was concerned.

During the onsite visit conducted on 4/14/2021, LPA observed 2 staff who were in the facility supervising the residents. LPA observed a staff (S2) could not hear LPA when LPA stood behind S2 asking a question. Per licensee, S2 had some hearing loss. Licensee also stated that it was possible that S2 did not or was not able to hear visitor calling from outside of the facility. Reporting party confirmed with LPA that he/she did not go to every room to check if a staff was present. During LPA’s visit, LPA observed the 2 residents including the resident in question appeared to be well kempt. LPA did not smell foul odor from the residents.

This Department has investigated the above allegation. Based on interviews and observations, the Department found that the above allegations are UNSUBSTANTIATED. Unsubstantiated findings indicate that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

This report was reviewed with Licensee and a copy of this report was emailed for signature.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20210409104525

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: VILLA-MAR RESIDENTIAL CARE HOME	FACILITY NUMBER: 430708498
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/05/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/19/2021 Section Cited CCR 87219(a)	1 2 3 4 5 6 7	87219 Planned Activities: (a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities…	1 2 3 4 5 6 7	Licensee already arranged activities for the residents to attend regularly.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews and observation, there was no planned activities. This posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai Ng	TELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5