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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708736
Report Date: 08/31/2021
Date Signed: 08/31/2021 04:29:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:VILLA VERDEFACILITY NUMBER:
430708736
ADMINISTRATOR:JULIETA EXTRAFACILITY TYPE:
740
ADDRESS:4751 CALLE DE TOSCATELEPHONE:
(408) 978-7937
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:6CENSUS: 4DATE:
08/31/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Dominica OlivaTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Joanne Roadilla conducted an unannounced Infection Control site visit today. LPA met with Administrator (ADM) Dominica Oliva to discuss the purpose of the visit.

LPA toured the facility inside and out with ADM. Facility was observed to have a designated entry point for universal symptom screening. Hand sanitizers were available and all staff present were observed wearing masks.

All bathrooms were inspected and observed supplied with hygiene products and with hand washing signs. Bedrooms, kitchen, dining room, living room, and the outside grounds of the facility were inspected. All fire exit routes were clear of obstruction. Medications, toxins, cleaning supplies, knives and sharp objects were secured. Facility also observed to have adequate supply of Personal Protective Equipment (PPEs).

LPA reviewed the facility COVID-19 related infection control policies and procedures with ADM including screening, surveillance testing, disinfecting, staffing, training, isolation, PPE use and inventory. Per ADM, all staff and residents are 100% vaccinated.

No deficiencies issued per Title 22 of the California Code of Regulations. LPA reviewed report with, and a copy provided to Dominica Oliva.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne RoadillaTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
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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