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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430708498
Report Date: 04/03/2024
Date Signed: 04/03/2024 07:20:29 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/14/2021 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20210714143311
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:
04/03/2024
UNANNOUNCEDTIME BEGAN:
02:03 PM
MET WITH:Marina SampaniTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility did not meet resident's needs.
INVESTIGATION FINDINGS:
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On 4/3/2024, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint inspection. LPA met with Administrator Marina Sampani explained the purpose of the visit.

The Department investigated the allegation that facility did not meet resident’s needs and based on interviews with staff from the Day Program, R1 has to come Program on multiple occasions with dried feces in their diaper.

Therefore, based on interviews and information collected, the above allegation is determined to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

A copy of this report and the Appeal Rights are provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
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 2
Control Number 26-AS-20210714143311
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: VILLA-MAR RESIDENTIAL CARE HOME
FACILITY NUMBER: 430708498
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/04/2024
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...
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Licensee has corrected the deficiency.
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This requirement was not met when R1 arrived at Day Program on multiple occasions with dried feces in their diaper.
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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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2