435200957-4-25-2024-26-AS-CDOS-D4NVTZ-20240425164358

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200957
Report Date: 04/25/2024
Date Signed: 04/25/2024 04:44:04 PM

Document Has Been Signed on 04/25/2024 04:44 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 AMOR		FACILITY NUMBER:	435200957
ADMINISTRATOR:	VALIN, A & V		FACILITY TYPE:	740
ADDRESS:	17605 HILL ROAD		TELEPHONE:	(408) 782-6767
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	6	CENSUS: 4	DATE:	04/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Virgil Valin		TIME COMPLETED:	04:45 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) Christine Dolores arrived unannounced to conduct the facility's annual required - 1 year inspection. LPA met with Administrators, Amor and Virgil Valin. LPA toured the facility with staff to include 5 resident bedrooms, staff bedrooms, living room, kitchen, laundry room, and backyard. All fire exits were free and clear of obstruction. 2 staff members present are fingerprint cleared and associated to the facility. Fire extinguisher last serviced on 12/08/2023. Carbon monoxide detector observed operable. Fire place observed screened. Kitchen observed with at least 7 days worth of non-perishable foods and 2 days worth of perishable foods. Refrigerator temperature maintained 37 degrees Fahrenheit. Freezer temperature maintained at 0 degrees Fahrenheit. Sharp objects, chemicals, and disinfectants observed locked. Resident bedrooms observed with adequate lighting, bed, linens, dresser, and night stands. Bathroom observed with hygiene products. Shower observed with grab bars and non-slip mats. Bathroom hot water temperature maintained at 108 degrees Fahrenheit. The facility has an emergency disaster plan. The facility's last emergency disaster drill was conducted in April 2023. Facility was advised. Facility has emergency lighting. The facility has an infection control plan, however, LPA was unable to review the infection control plan in the facility. Administrator states to ensure the infection control plan will be available in the facility. LPA observed the facility's PPE supplies. SEE LIC809-C.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

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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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 AMOR	FACILITY NUMBER: 435200957
	VISIT DATE: 04/25/2024

NARRATIVE

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LPA reviewed 4 residents records. 4 out of 4 resident records observed maintained to include an admission agreement, medical assessment, TB result, appraisal/needs and services plan, personal rights, consent form, and safeguard of personal property and valuables. 4 out of 4 resident centrally stored medication records observed maintained. 4 residents were interviewed during visit.

LPA reviewed 4 staff files to include a 1st aid certification, health screening, TB result, personnel record, and fingerprint clearance. LPA reviewed the staff member's training records. 3 staff members were interviewed during visit.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. Advisory note provided. This report was reviewed with Administrator Virgil Valin and a copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/25/2024 04:44 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 AMOR	FACILITY NUMBER: 435200957
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 observation, interview, and record review the licensee did not ensure emergency drills are being conducted quarterly in which the last emergency drill conducted was in April 2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2024
	Plan of Correction
1 2 3 4	Licensee will conduct the emergency drill, ASAP. Licensee will send the emergency drill to LPA Dolores via email by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC809 (FAS) - (06/04)

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