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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708498
Report Date: 08/17/2023
Date Signed: 08/17/2023 04:45:01 PM


Document Has Been Signed on 08/17/2023 04:45 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
CENTRAL COAST CR/RES, 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: 3DATE:
08/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Marina SampaniTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator (ADM) Marina Sampani. The purpose of the visit was to respond to a report that there were no staff working at the facility.

LPA Marrufo arrived at the facility at 3:00 PM and observed ADM Sampani speaking with witness W1. W1 stated to have arrived at the facility at 1:45 PM and was greeted by a resident. W1 stated the resident told W1 that the only staff at the facility was napping and there were no other staff at the facility. W1 then called 911. ADM told LPA that when ADM observed police arrive at the facility, ADM came to the front of the house and met with W1.

LPA Marrufo toured the facility and interviewed staff, residents, and ADM. ADM stated that the door is not to be used by visitors and visitors should instead use the sliding door at the kitchen. LPA Marrufo did not observe any signs directing visitors to use the sliding kitchen door. LPA Marrufo observed that the doorbell at the front door did not work. LPA Marrufo observed that the kitchen telephone had a faint sound and disconnected once it was picked up. LPA Marrufo observed a second land line telephone in the common area. The second land line did not make a sound when called. LPA Marrufo observed a bedroom in the facility that had resident R1 sleeping in one bed and staff S1 sleeping in the other. R1 stated that S1 sleeps in that bed overnight and naps in the bed during the day. S1 stated to have been napping earlier in the day. S1 stated to be hard of hearing and LPA observed S1 to be wearing a hearing aid. S1 stated to not be able to hear the kitchen land line telephone from the bedroom area, but is able to hear it if S1 is in the dinning room.

An LIC9102 Advisory Note was issued. Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D for more information. This report was reviewed with ADM Sampani and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023
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 2


Document Has Been Signed on 08/17/2023 04:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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: 08/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/18/2023
Section Cited
CCR
87468.1(a)(1)

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Personal Rights of Residents in All Facilities: 87468.1(a)(1): (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
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Licensee agrees to submit a plan of correction by POC Due Date stating how Licensee shall prevent staff from sleeping in resident bedrooms.
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(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: LPA Marrufo observed S1 sleeping in a bed in R1's bedroom, which poses an immediate safety risk to residents in care.
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Type A
08/18/2023
Section Cited
CCR87311

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Telephones 87311: All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed in the telephone directory under the name of the facility.
This requirement was not met at evidenced
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Licensee agrees to submit a plan by POC Due Date to have functioning telephone service at the facility.
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by: LPA Marrufo observed two out of two land line telephones were not functioning properly during visit, which poses an immediate safety risk to residents in care.
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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 YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2