435200957-4-24-2025-26-AS-CKAI-DG2UG4-20250424153344

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435200957
Report Date: 04/24/2025
Date Signed: 04/24/2025 03:33:55 PM

Document Has Been Signed on 04/24/2025 03:33 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/ DIRECTOR:	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: 6	DATE:	04/24/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:30 PM
MET WITH:	Ester Honrado		TIME VISIT/ INSPECTION COMPLETED:	03:40 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) Christine Dolores arrived unannounced to conduct the facility's annual required - 1 year inspection. LPA met with staff, Ester Honrado. Administrator/Licensees Virgil and Amor Valin was unable to meet LPA at the facility. 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. 3 staff members present are fingerprint cleared and associated to the facility. Fire extinguisher last serviced on 01/06/2025. 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 40 degrees Fahrenheit. Freezer temperature maintained at 0 degrees Fahrenheit. Chemicals observed secured. LPA observed a resident's prescription injection that was accessible inside the refrigerator. All residents are able to access the refrigerator. Staff states they do not lock the resident's injections in the refrigerator. LPA advised to purchase a lock box/bag to place the refrigerated medications inside to ensure the medication is inaccessible to other residents in care. During visit, staff placed the resident's refrigerated medication in the staff living quarters which is off limits to the residents. Staff states that after the resident self administers their injection, they place the needle in the trash. It was stated that the facility does not have an appropriate container to properly dispose of the resident's needles. LPA advised to ensure needles are disposed of properly. See LIC809-C.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 04/24/2025

NARRATIVE

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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 113.5 degrees Fahrenheit.

Inside 1 of the resident bedrooms, LPA observed a prescription mouthwash that was left accessible. Based on review of the resident's file, the resident is not able to store their own medication. Staff was advised to ensure all centrally stored medications are not accessible to residents in care.

The facility has an emergency disaster plan. The facility's last emergency disaster drill was completed in January and April 2025. The facility has an infection control plan.

LPA reviewed 3 residents records. 3 out of 3 resident records observed maintained to include an admission agreement, updated medical assessment, TB result, updated appraisal/needs and services plan, personal rights, consent form, and safeguard of personal property and valuables. 3 out of 3 resident centrally stored medication records observed maintained. 1 out of 3 resident has cash resources being maintained by the facility, which was reviewed with staff. No issues noted.

LPA reviewed 3 staff files to include a 1st aid certification, health screening, TB result, personnel record, and fingerprint clearance. 3 staff are provided training in compliance with Title 22 regulations.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. The plan of corrections were reviewed with Administrator/Licensees Amor and Virgil Valin via telephone.

This report was reviewed with staff, Ester Honrado and a copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/24/2025 03:33 PM - It Cannot Be Edited

Created By: Christine Kabariti On 04/24/2025 at 02:55 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: VILLA AMOR	FACILITY NUMBER: 435200957
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/24/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above wherein LPA observed 2 prescription medications that were accessible in the refrigerator and resident's bedroom which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2025
	Plan of Correction
1 2 3 4	Licensee immediately secured the medications. Licensee will submit a written statement and plan to ensure compliance with the section cited above to LPA Kabariti via email by POC due date.

Type A

Section Cited

CCR

87628(b)(3)

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that syringes and needles are disposed of as specified in Section 87303(f)(2). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above wherein the facility is not disposing of a resident's needles appropriately after each use which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2025
	Plan of Correction
1 2 3 4	Licensee will order a sharps container. Licensee will send a proof of purchase of the sharps container to LPA Kabariti via email by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:

	Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025

LIC809 (FAS) - (06/04)

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