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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708498
Report Date: 06/07/2024
Date Signed: 06/07/2024 11:22:40 AM


Document Has Been Signed on 06/07/2024 11:22 AM - 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: DATE:
06/07/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Marina SampaniTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo and Licensing Program Manager (LPM) Jackie Jin conducted an Informal Office meeting and met with Licensee Marina Sampani and Mae Sampani.

During office visit, LPA and LPM discussed with Licensee Marina Sampani the plans for future facility operations.

LPA and LPM advised Licensee Sampani that there needs to be a certified administrator at the facility and informed Licensee about the requirements to become a certified administrator.

LPA and LPM discussed that residents need supervision at all times and volunteers cannot be at the facility without staff supervising them. LPA and LPMs discussed that on 05/24/2024 an LPA observed a volunteer sleeping at the facility during a visit in a chair in a vacant resident room.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D for more information.

During visit, Licensee Marina Sampani provided a copy of the current LIC500 Personnel Report form.

This report was reviewed with Licensee Marina Sampani and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024
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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Document Has Been Signed on 06/07/2024 11:22 AM - 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: 06/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/08/2024
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. In facilities licensed for sixteen or more,
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Licensee shall submit a Plan of Correction by POC date to ensure that there will be staff at all times in sufficient numbers and competent to provide the services necessary to meet resident needs.
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sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by: Licensee did not ensure that staff were present at the facility when a Licensing Program Analyst observed there was a volunteer sleeping at the facility and no staff to supervise the residents, 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: 06/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/07/2024 11:22 AM - 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: 06/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/08/2024
Section Cited
CCR
87411(j)

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(j) Volunteers may be utilized but may not be included in the facility staffing plan. Volunteers shall be supervised. This requirement was not met as evidenced by: Licensee did not ensure that a
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Licensee shall submit a Plan of Correction by POC date to ensure that volunteers at the facility are supervised by staff when they are at the facility.
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volunteer was left unsupervised on 05/24/2024 when a Licensing Program Analyst conducted a 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: 06/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024
LIC809 (FAS) - (06/04)
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