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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708498
Report Date: 01/28/2025
Date Signed: 01/28/2025 03:18:34 PM

Document Has Been Signed on 01/28/2025 03:18 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/
DIRECTOR:		SAMPANI, MARINAFACILITY TYPE:
740
ADDRESS:333 LASTRETO AVENUETELEPHONE:
(408) 730-8632
CITY:SUNNYVALESTATE: CAZIP CODE:
94085
CAPACITY: 6CENSUS: 1DATE:
01/28/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:Marina SampaniTIME VISIT/
INSPECTION COMPLETED:
03:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine (Dolores) Kabariti arrived unannounced to conduct a case management – other visit. LPA met with Licensee, Marina Sampani. The purpose of the visit is to follow-up on a facility closure notification the Department received on 01/21/2024.

On 08/01/2024, the licensee verbally mentioned plans to close the facility by the end of year 2024. On 01/21/2025, the Department received the facility’s notification regarding their intent to close effective 01/30/2025. Licensee states they did not provide a written notice to R1 as the discussion was all done verbally. Licensee states a plan to provide R1 and R1's power of attorney (POA) with a 60-day written notice following Health and Safety Code Section 1569.682. Upon following up with the licensee, it was found that a resident (R1) has a petition for the licensee to continue providing care and supervision for R1, after the facility closure. This petition is still pending court approval. Licensee states that R1 will continue to remain in the facility until R1’s living situation has been resolved with the court and will follow-up with R1's POA regarding possible relocations. LPA discussed with the Licensee about her succession plan as the licensee is the sole proprietor.

The Licensee plans to rescind the forfeiture letter and will submit the new forfeiture letter with the new effective date of closure, reason for closure, and closure plan.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Licensee Marina Sampani and a copy of there report and appeal rights was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/28/2025 03:18 PM - It Cannot Be Edited


Created By: Christine Dolores On 01/28/2025 at 03:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 01/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/29/2025
Section Cited
CCR
1569.682(a)(2)

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(a) A licensee of a licensed residential care facility for the elderly shall, prior to transferring a resident of the facility to another facility or to an independent living arrangement as a result of the forfeiture of a license, as described in subdivision (a), (b), or (f) of Section 1569.19, or a change of use of the facility pursuant to the department’s regulations, take all reasonable steps to transfer affected residents safely and to minimize possible transfer trauma, and shall, at a minimum, do all of the following: (2) Provide each resident or the resident’s responsible person with a written notice no later than 60 days before the intended eviction. The notice shall include all of the following: This requirement is not met as evidenced by:
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Licensee states they will rescind the facility's forfeiture letter and resubmit the forfeiture letter with the new closure date. Licensee will serve the resident and resident's responsible person with a 60 day written notice to include
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Based on interview, record review and obervation the licensee did not comply with the section cited as the licensee did not provide resident (R1) and responsible person with a written notice no later than 60 days before the intended closure which poses/posed an immediate health safety and personal rights risk to persons in care.
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all items under Health and Safety Code Section 1569.682. Licensee will send the 60 days written notice that was served to the resident to LPA via email by POC due date of 01/29/2025.

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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 Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
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