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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708498
Report Date: 08/01/2024
Date Signed: 08/01/2024 02:05:35 PM


Document Has Been Signed on 08/01/2024 02:05 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: 2DATE:
08/01/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Marina SampaniTIME COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - other visit. LPA met with Licensee, Marina Sampani.

The purpose of the visit was to follow-up on the written plan of correction from the facility's annual inspection on 05/24/2024.

On 06/17/2024, LPA Dolores called the facility's number and Licensee's cell phone number multiple times to follow-up on the plan of correction. LPA did not receive a return call.

During visit, the Licensee states they had sent LPA Dolores the plan of correction 3 times via email. LPA Dolores did not receive 3 out of 3 emails. The Licensee's daughter forwarded the emails to LPA Dolores. It was observed the email address that the plan of correction was sent to was incorrect.

LPA reviewed the plan of corrections during visit. No further follow-up is needed at this time.

No deficiencies are cited per California Code of Regulations, Title 22.

This report was reviewed with Licensee, Marina Sampani and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2024
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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