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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435200085
Report Date: 12/19/2023
Date Signed: 12/19/2023 05:21:13 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
12/18/2023 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20231218120700
FACILITY NAME:VILLA ANTONIOFACILITY NUMBER:
435200085
ADMINISTRATOR:JOSEPH ANTHONY OLIVAFACILITY TYPE:
740
ADDRESS:1494 KOCH LANETELEPHONE:
(408) 979-1757
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:6CENSUS: DATE:
12/19/2023
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Administrator Joseph Anthony OlivaTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff verbally abusive to a resident.
Staff did not report physical and verbal abuse to licensing.
INVESTIGATION FINDINGS:
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On December 19, 2023, Licensing Program analysts (LPA's) Manuel Monter, Mita Partoza and Licensing Program Manager (LPM) Romeo Manzano conducted an unannounced complaint investigation. LPA's and LPM with Administrator (ADM) Joseph Anthony Oliva, and explained the purpose of the visit.

On December 18, 2023, the department received a complaint alleging facility staff verbally abused a resident.

Staff verbally abusive to a resident.

On December 19, 2023, LPA's and LPM interviewed 3 out of 3 staff. 2 Out of 3 staff interviewed stated that staff S1 verbally abused R1 sometime in October 2023. 2 out of 3 staff alleged S1 would also verbally abuse resident R2 who no longer lives at the facility, by screaming at him/her.
Page 1 out of 2.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
12/18/2023 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20231218120700

FACILITY NAME:VILLA ANTONIOFACILITY NUMBER:
435200085
ADMINISTRATOR:JOSEPH ANTHONY OLIVAFACILITY TYPE:
740
ADDRESS:1494 KOCH LANETELEPHONE:
(408) 979-1757
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:6CENSUS: DATE:
12/19/2023
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Administrator Joseph Anthony OlivaTIME COMPLETED:
05:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff physically hit a resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On December 19, 2023, Licensing Program analysts (LPA's) Manuel Monter, Mita Partoza and Licensing Program Manager (LPM) Romeo Manzano conducted an unannounced complaint investigation. LPA's and LPM with Administrator (ADM) Joseph Anthony Oliva, and explained the purpose of the visit.

On December 18, 2023, the department received a complaint alleging facility staff physically abused a resident.

On December 19, 2023, LPA's and LPM interviewed 3 Out of 3 staff. 3 Out of 3 staff interviewed denied the alligation that staff physically hit a resident. 2 out of 3 staff interviewed stated staff S1 would handle the residents abrassively. 2 staff members observed staff S1 pushing R2 back down on his/her wheelchair, when attempting to get up.

Page 1 out of 2
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 26-AS-20231218120700
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/19/2023
NARRATIVE
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LPA's interviewed 6 out of 6 residents. 4 Out of 6 residents denied the allegation. 2 residents were not able to respond to interview due to neurocognitve disorder.

Based on the interviews conducted with residents and staff & records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited, Exit interview conducted with Administrator, Joseph Anthony Oliva and a copy of the report was provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 26-AS-20231218120700
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/19/2023
NARRATIVE
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Staff did not report physical and verbal abuse to licensing.

On December 19, 2023, LPA's and LPM interviewed 3 out of 3 staff. 2 Out of 3 staff interviewed stated that staff S1 verbally abused R1 sometime in October 2023. Staff S2 and S3 stated they did not report because they were afraid to report it. Based on staff facility file, 3 out of 3 staff did not have training on mandated reporting.

Based on a review of the evidenced provided, S1 was verbal berating R1 (“why do you have to know everything”, “you’re so crazy”, “you’re making me mad now”, and “see, it’s broken now [as if the breaking was R1’s fault]”). S1 clapping his/her hands loudly in the face of R1; slamming the cord forcefully into the lamp and breaking the cord connection and slamming of the cord was jolting.

Based on interviews and evidenced reviewed the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D.
This report was reviewed with Administrator Joseph Anthony Oliva and a copy of the report was provided. Appeal Rights was provided.

Page 2 out of 2.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 26-AS-20231218120700
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/20/2023
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilites (a)(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement was not met as evidenced by;
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ADM stated he will send a plan of action on how the facility will ensure staff accord residents with dignity. ADM will send the plan of action by POC date, 12/20/2023.
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Based on evidence reviewed and interviews with conducted, 2 Out of 3 staff admitted that S1 verbally abused resident R1. The facility staff did not acccord dignity to residents in care. This poses an immideate threat to health, saftey and personal rights risk to person in care.
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Type A
12/20/2023
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements (a)(1)(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by
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ADM stated he will send a plan of action on how facility staff will meet reporting requirments. ADM will send plan of action to LPA by POC date, 12/20/2023.
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Based on evidence reviewed & interviews with conducted, 2 Out of 3 staff admitted that S1 verbally abused resident R1. 2 Out of 3 staff acknowledge the verbal abuse occured a month ago & they did not report it. This poses an immideate threat to health, saftey & personal rights risk to persons in care.
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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: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 26-AS-20231218120700
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/20/2023
Section Cited
HSC
1569.50(a)(3)
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1569.50 Denial, suspension or revocation of license; ...exclusion from licensee without right to petition for reinstatement (a)(3) Conduct that is inimical to the health, morals, welfare, or safety ... from the facility or the people of the State of California. This requirement was not met as evidenced by;
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ADM stated that S1 will be terminated and removed effective today. ADM stated S1 will move from the facility and will be relocated at Licensee's home.
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Based on interviews conducted, and evidenced reviewed, the facility staff verbally abused a resident in care. 2 Out of 3 staff admitted a staff member verbally abused a resident. This poses an immediate threat to residents health, safety and personal rights.
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Type B
12/26/2023
Section Cited
HSC
1569.625(b)(1)
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1569.625 Staff training; legislative findings; contents (b)(1)The department shall adopt regulations to require staff members of residential care facilities for the elderly ...This training shall consist of 40 hours of training....
This requirement was not met as evidenced by;
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ADM stated he/she will provide training for staff. ADM stated he will send documentation to LPA by POC date, 12/26/2023.
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Based on staff training records review & interviews, Staff did not receive training on mandated reporting/elder abuse & filling out SOC341. ADM also acknowledged he/she did not provide training on mandated reporting of elder abuse. This poses an immediate threat to residents health, safety & personal rights
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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: Romeo ManzanoTELEPHONE: (408) 388-2297
LICENSING EVALUATOR NAME: Manuel MonterTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6