430708498-8-25-2023-26-AS-KHOS-CZ4KGG-20240102065332

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430708498
Report Date: 08/25/2023
Date Signed: 08/25/2023 05:04:58 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
08/18/2023 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20230818150239

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: 3	DATE:	08/25/2023
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Marina Sampani		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Facility did not have a working telephone
Staff did not answer the door and were not responsive to knocks on the door

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Administrator (ADM) Marina Sampani.

LPA Marrufo previously cited the facility for not having a working telephone during a case management visit on 08/17/2023, the day the allegation occurred.

On 08/17/2023 at 1:40 PM, a witness stated to have knocked on the faciity door and windows and did not receive a response from staff or observe a staff at the facility. The witness called the facility telephone number but there was no response. The witness stated that a resident arrived to the facility from an appointment and the resident stated that there were no staff at the facility. The witness then called police at 2:33 PM and police arrived at 3:09 PM. When police arrived, Administrator (ADM) Maria Sampani appeared from within the facility and met with the witness and police. See LIC9099-C for more information. Page 1 of 2.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

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 3

Control Number 26-AS-20230818150239

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 08/25/2023

NARRATIVE

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LPA Marrufo arrived at the facility shortly afterwards and observed ADM speaking with the witness.

On 08/17/2023, LPA Marrufo interviewed ADM, who stated to have been in her bedroom inside the facility resting and reading a magazine.

LPA Marrufo also interviewed a facility staff who stated to have been napping in a resident room during visit.

LPA Marrufo cited the facility for not having a working telephone and for having a staff sleep in a resident room during a case management visit on 08/17/2023, the day the incident occurred.

During today's visit on 08/25/2023, LPA observed signs on the main entrance door and sliding kitchen glass door advising visitors to enter through the sliding kitchen door. The sign also included the telephone numbers for the facility and ADM's mobile telephone number. LPA Marrufo observed that the facility telephone in the kitchen functioned properly and had a dial tone.

Based on records review, interviews with residents and staff, and observations, there is preponderance of evidence to prove the alleged violations did occur, therefore the allegation is SUBSTANTIATED.

See 9099-D for deficiencies cited per the California Code of Regulations, Title 22.

This report was reviewed with ADM Marina Sampani and a copy of the report and appeal rights were provided.

Page 2 of 2. END REPORT.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20230818150239

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/25/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/26/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a) Personnel Requirements - General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Licensee did not ensure	1 2 3 4 5 6 7	Licensee agrees to submit a plan to place signs on the main entrance door and sliding kitchen door telling visitors to knock on the sliding kitchen door. The sign should also include the contact telephone numbers for the facility and the administrator's mobile number. Deficiency has been corrected during visit
	8 9 10 11 12 13 14	that a staff responded to knocking on the facility door and windows, which poses an immediate 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: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3