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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708498
Report Date: 12/08/2021
Date Signed: 12/08/2021 03:10:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 HOMEFACILITY NUMBER:
430708498
ADMINISTRATOR:SAMPANI, MARINAFACILITY TYPE:
740
ADDRESS:333 LASTRETO AVENUETELEPHONE:
(408) 730-8632
CITY:SUNNYVALESTATE: CAZIP CODE:
94085
CAPACITY:6CENSUS: 2DATE:
12/08/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Marina Sampani, ADMTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management investigation visit, and met with administrator(ADM) Marina Sampani. LPA addressed the purpose of today's visit to ADM that LPA want to figure out why the facility phone cannot leave message and why ADM never returned the message for ADM's cell phone.

LPA checked with ADM for the facility phone answer machine. The answer machine was full of left messages. LPA asked ADM to delete all the old messages. LPA called the facility phone again, then LPA can leave message. ADM then was able to played back the message that LPA left in the answer machine. ADM stated ADM does not answer the phone or return the message for ADM's cell phone because ADM did not recognize the caller.

ADM stated that the current census of the facility is 2. LPA toured the facility with ADM. LPA observed one staff working in facility. One resident was out for day program, and one resident was sleeping at his bedroom. Dinning room, family room, kitchen, 4 resident bedrooms, 4 bathrooms, and one office were observed in facility.

ADM stated all the staff and residents are fully vaccinated, and are scheduling for booster shots.

No citation was issued today. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was emailed to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
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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