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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200957
Report Date: 04/19/2022
Date Signed: 04/19/2022 12:13:25 PM

Document Has Been Signed on 04/19/2022 12:13 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:VILLA AMORFACILITY NUMBER:
435200957
ADMINISTRATOR:VALIN, A & VFACILITY TYPE:
740
ADDRESS:17605 HILL ROADTELEPHONE:
(408) 782-6767
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 6CENSUS: 4DATE:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:AMOR & VIRGIL VALINTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a required 1-year annual inspection to focus on infection control. LPA met with Administrators Amor and Virgil Valin.

During visit, LPA toured the facility inside and outside to include the dining room, living room, kitchen, resident rooms, bathroom, laundry room, and backyard. All fire exit routes were free and clear of obstruction.

Facility observed to have a designated entry point for COVID-19 symptoms screening for all visitors, residents and staff. Hand sanitizer available throughout the facility. Bathrooms observed to be supplied with hygiene products, paper supplies, and hand washing signs. The following posters were observed to include: symptoms of COVID, social distancing, visitor policy, and hand washing. Facility cleans and disinfect multiple times daily and as needed. Trash can with lid was observed. Facility has a designated visitation area located in the backyard. LPA observed supply of Personal Protective Equipment (PPE) and advised to keep a sufficient amount of gowns at the facility. All staff observed to be wearing a face mask. Staff are N95 fit tested. LPA reviewed facility's policies and procedures to isolation and infection control training.

LPA informed the Administrator to review PIN 22-13-ASC and submit Infection Control Plan to CCLD by 06/30/2022.

The following documents were requested to include an updated LIC610 and Administrator Certificate by 04/20/2022.

No citations were issued per the California Code of Regulations, Title 22.

This report was reviewed with Virgil Valin and a copy of this report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2022
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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