435200085-10-24-2023-26-AS-MMOR-CWX27L-20231024170853

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200085
Report Date: 10/24/2023
Date Signed: 10/24/2023 05:09:07 PM

Document Has Been Signed on 10/24/2023 05:09 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 ANTONIO		FACILITY NUMBER:	435200085
ADMINISTRATOR:	JOSEPH ANTHONY OLIVA		FACILITY TYPE:	740
ADDRESS:	1494 KOCH LANE		TELEPHONE:	(408) 979-1757
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY:	6	CENSUS: 5	DATE:	10/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:10 PM
MET WITH:	Administrator Joseph Antony Oliva		TIME COMPLETED:	04:40 PM

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	Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Joseph Anthony Oliva. During visit, LPA observed 5 residents and 2 staff on duty(not including ADM). LPA toured the facility inside out with ADM which included; the Living room, kitchen, dinning room, 2 restrooms and 6 residents bedrooms. The staff area of the facility was also inspected. Front yard and backyard were inspected. There was no obstruction to block the walkways. Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication closet, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 77 degrees F, and hot water temperature was measured to range between 112-115 degrees F in both resident bathrooms. While touring the backyard, LPA observed a tool bag (with included scissors) and a block of knives near the storage units, across bedroom # 4's outside exit (Photographs were taken). LPA asked ADM if the residents have access to the back yard. ADM stated the residents can come to the backyard. LPA also observed can of paint and can of WD-40 accessible to residents in care. (Photographs were taken.) While touring the backyard, LPA observed a two storage units. LPA asked ADM to open the one door storage unit and LPA observed it being used as storage. LPA requested ADM open the other storage unit with two doors. ADM opened the door and there was a mattress on the ground with blankets. ADM stated the storage unit is used as a "rest area" but don't sleep there. ADM stated the storage unit is a "rest area" and no one lives there. Page 1 out of 2.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

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 4

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 ANTONIO	FACILITY NUMBER: 435200085
	VISIT DATE: 10/24/2023

NARRATIVE

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LPA interviewed Staff S1 and S2. LPA consulted with LPM Manzano if LPM can assist with staff interview in Filipino language (Tagalog). LPM conducted interviews with Staff S1 and S2 on the phone. S1 stated as of August 2023, he/she and his/her child stay in the storage room while waiting for his/her spouse from work who get off from work between 12am to 1am. S1 admitted he/she is resting/sleeping in storage room with his/her 6-year-old child until his/her spouse picks them up. S1 works from 7am to 3pm and often gets off late from work wherein he/she does not have a childcare, so he/she was allowed to occupy storage room. Staff (S2) was interviewed who stated that the storage room was built for their previous male staff in the facility. S2 stated that male staff gets off work early mornings wherein they opted to sleep in the living room instead of going home at dawn wherein licensee/administrator has decided to convert the storage room as a designated staff resting area until present. S2 confirmed that S1 utilizes the storage room along with his/her 6-year-old child while waiting for his/her spouse gets off from work at 12am. LPM informed S1 and S2 agreed and understood that no staff or any individual is allowed to sleep in the following areas without building permit and fire clearance such as but not limited storage room, living room, and garage.

Fire extinguisher was serviced in May 03, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on December 2021. ADM stated "we haven't done one in the past year."

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 3 staff (S1 to S3) and 3 residents (R1-R3).

LPA and ADM discussed the storage unit. ADM agreed and understood that no staff or any individual is allowed to sleep in the following areas without building permit and fire clearance such as but not limited storage room, living room, and garage.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with Administrator Joseph Anthony Oliva. Appeal rights were provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 10/24/2023 05:09 PM - 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 ANTONIO	FACILITY NUMBER: 435200085
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPA observed a can of WD-40 lubricant and can of paint next to the storage units in the facility's backyard. ADM stated the residents have access to the backyard. ADM stated he/she has dementia residents. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/25/2023
	Plan of Correction
1 2 3 4	ADM will send a plan of action on how the facility will ensure disinfectants, cleaning solutions, poisons and other items that could pose a danger to residents are properly stored, inaccessible to residents in care. ADM will send by POC date, 10/25/2023.

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPA observed several knives and a tool bag containing things such as scissors next to the storage unit in the backyard. ADM stated the residents have access to the backyard. ADM stated he has residents with dementia. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/25/2023
	Plan of Correction
1 2 3 4	ADM will send plan of action on how the facility will secure knives and tools in the facility to ensure they are not accessible to residents in care. ADM stated he will send to LPA by POC date, 10/25/2023.

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: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 10/24/2023 05:09 PM - 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 ANTONIO	FACILITY NUMBER: 435200085
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation & interview, the ADM did not comply with the section cited above. LPA observed a mattress in the storage unit. ADM stated the storage unit is being used as a rest area. S1 admitted that he/she sleeps in the storage room with his/her 6-year-old child until his/her spouse picks them up. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/31/2023
	Plan of Correction
1 2 3 4	ADM will photo documentation showing the storage area is no longer being used as a sleeping area. ADM stated he will also send a letter of understanding stating no staff or any individual is allowed to sleep in the following areas without building permit and fire clearance such as but not limited storage room, living room, and garage.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview & record review, the ADM did not comply with the section cited above. ADM stated the facility has not done a fire drill in the past year. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/31/2023
	Plan of Correction
1 2 3 4	ADM stated he will conduct a fire drill and send documentation to LPA by 10/31/2023.

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: Romeo Manzano	TELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel Monter	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4