430708736-10-13-2021-26-AS-KHOS-C88K4N-20211028073438

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 430708736
Report Date: 10/13/2021
Date Signed: 10/13/2021 05:07:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/13/2021 and conducted by Evaluator Joanne Roadilla

COMPLAINT CONTROL NUMBER: 26-AS-20210513162317

FACILITY NAME:	VILLA VERDE		FACILITY NUMBER:	430708736
ADMINISTRATOR:	JULIETA EXTRA		FACILITY TYPE:	740
ADDRESS:	4751 CALLE DE TOSCA		TELEPHONE:	(408) 978-7937
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95118
CAPACITY:	6	CENSUS: 4	DATE:	10/13/2021
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Dominica Oliva		TIME COMPLETED:	12:20 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility not providing enough food to resident(s).

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Joanne Roadilla conducted an unannounced complaint visit to deliver complaint investigation findings. LPA met with Administrator, Dominica Oliva and discussed the purpose of the visit.

On 05/13/2021, the Department received a complaint with the allegation that the facility is not providing enough food to resident(s). On 05/20/21, an initial unannounced 10-day investigation visit was conducted at the facility. The Department interviewed 4 staff (S1 to S4) and 3 residents (R1 to R3). During the visit, residents were observed having lunch. The facility refrigerator, freezer and pantry were inspected and observed with a minimum of 2-day supply of perishable and one-week supply of non-perishable food. The facility menu and resident records were also obtained.

Continued on 9099-C.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne Roadilla	TELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 26-AS-20210513162317

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 VERDE	FACILITY NUMBER: 430708736
	VISIT DATE: 10/13/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on staff interviews, the facility serves 3 meals and 2 snacks per day. The staff serves breakfast between 7-7:30am but they do not serve the residents altogether, it depends on who’s ready. Lunch is served all at the same time around 11:30am-12pm. Snacks are served between 1-5pm depending on who wants it or who’s awake. Dinner is served at 5pm for all residents. A light snack is also offered after dinner. Staff stated some residents do not eat at the same time as everyone else, some residents like to eat in their room, or some do not like to eat breakfast and prefer to sleep in.

Based on resident interviews, residents like the food at the facility and they are getting the food they want.

Based on records review, the facility has a weekly menu that staff prepare and serve to their residents. Staff stated that they follow the menu and would modify a little according to resident’s needs and request. They would ask the residents what kind of food they like before they finalize the menu.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

No deficiencies cited during today's visit. Report was discussed with and a copy provided to Dominica Oliva.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne Roadilla	TELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2