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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200957
Report Date: 08/14/2024
Date Signed: 08/14/2024 03:50:35 PM


Document Has Been Signed on 08/14/2024 03:50 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 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:
08/14/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Virgil ValinTIME COMPLETED:
03:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – deficiencies visit. LPA met with Administrator, Virgil Valin.

During a complaint investigation for control number: 26-AS-20220411150326, a violation was observed.

Based on record review, the incident with resident (R1) occurred on 04/06/2022. The Licensee did not submit the incident report until requested on 04/19/2022. The Department received the incident report 7 days after the occurrence date.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D.

This report was reviewed with Administrator, Virgil Valin and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024
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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Document Has Been Signed on 08/14/2024 03:50 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: 08/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/22/2024
Section Cited
CCR
87211(a)(1)

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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. … This requirement is not met as evidenced by:
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Licensee will submit a written plan of the section cited to LPA Dolores via email by POC due date.
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Based on interview, record review and observation the licensee did not ensure to submit a written incident report to the Department regarding the incident that occurred with resident (R1) which poses a potential health, safety, and 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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2