430708498-4-3-2024-26-AS-KHOS-D4KHV6-20240422063125

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430708498
Report Date: 04/03/2024
Date Signed: 04/03/2024 07:23:19 PM

Unsubstantiated

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
06/29/2021 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20210629163104

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:	04/03/2024
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Marina Sampani		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not assist resident with medical needs

INVESTIGATION FINDINGS:

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

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 staff did not assist resident with medical needs and based on an interview with R1’s provider, there is not a preponderance of evidence to prove or disprove the allegation occurred. The allegation is therefore unsubstantiated.

No deficiencies cited and exit interview was conducted.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 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)

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