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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201796
Report Date: 11/04/2024
Date Signed: 11/06/2024 08:28:59 AM

Document Has Been Signed on 11/06/2024 08:28 AM - 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:NUEVA VISTAFACILITY NUMBER:
435201796
ADMINISTRATOR/
DIRECTOR:		WEINSTEIN, MICHAELFACILITY TYPE:
735
ADDRESS:18225 HALE AVENUETELEPHONE:
(408) 465-8280
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 72CENSUS: 66DATE:
11/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Amando GubaTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - incident visit based on 3 incident reports received for 3 residents (R1 - R3) who eloped from the facility. LPA met with Assistant Administrator (AA), Armando Guba.

On 10/31/2024, the Department received 3 incident reports reporting R1 - R3 who eloped from the facility the night of 10/24/2024. The incident report stated that on 10/24/2024 around 8:45PM, staff conducted a room check and observed R1 - R3 were missing from the facility. A missing persons report was called at 11:30PM. On 10/31/2024, LPA Marrufo spoke with the Administrator who stated that R1 was found, but R2 - R3 are still missing.

On 11/04/2024, LPA Dolores interviewed AA. Based on interview, on 10/24/2024 R1 - R3 was last seen at the facility after dinner time (from 5:30PM - 6:30PM). AA physically saw R1 - R3 around 7:15PM after the residents asked for the remote in the lounge area. Around 8:00PM, is when the bedtime medication pass started. Staff noticed R1 - R3 did not receive their bedtime medication and staff went to look for R1 - R3. After searching the facility, R1 - R3 was not found. AA stated they waited until after curfew (10PM) to call for a missing persons, in case R1 - R3 were to return. R1 - R3 did not return to the facility and staff called for a missing persons around 11:30PM. AA states to believe R1 - R3 exited from R1 and R2's bedroom window because the window screen was observed outside the the bedroom on 10/25/2024. It was stated that the bedroom window was observed closed the night R1 - R3 went missing.
See LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024
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: NUEVA VISTA
FACILITY NUMBER: 435201796
VISIT DATE: 11/04/2024
NARRATIVE
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AA stated that the day before R1's elopement, the residents mentioned to AA, that R1 was talking about a plan to leave the facility. AA informed the staff to keep a close eye on R1.

AA stated due to previous behaviors, R1 was pending a new placement prior to the elopement. R2 - R3 did not show any signs of a plan to elope from the facility.

The review of records shows that R1 - R3 is able to leave the facility unassisted. Based on the facility's program, R1 - R3 are able to leave the facility with staff support.

On 10/31/2024, R1 - R3 was discharged from the facility.

Based on interview and record review, on 10/16/2024 R1 was served a 30 day eviction for the reasons of not complying with the admission agreement and inability to meet the resident's needs. The Department was not informed of the 30 day eviction within 5 days of giving notice to the resident.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Assistant Administrator, Armando Guba and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/06/2024 08:28 AM - It Cannot Be Edited


Created By: Christine Dolores On 11/04/2024 at 11:16 AM
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: NUEVA VISTA
FACILITY NUMBER: 435201796

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/05/2024
Section Cited
CCR
80061(b)(1)(E)

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(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following: (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. This requirement is not met as evidenced by:
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Licensee will conduct training with the Assistant Administrator and applicable staff of Title 22 Section 80061 - Reporting Requirements. Licensee will submit the training document to LPA Dolores via email by
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Based on interview, record review and observation the licensee did not comply with the section cited wherein the Licensee did not inform the Department of R1 - R3's elopement on 10/24/2024 until 10/31/2024, which poses an immediate health, safety and personal rights risk to persons in care.
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POC due date of 11/05/2024.
Type A
11/05/2024
Section Cited
CCR80068.5(a)

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(e) The licensee shall mail or fax to the Department a copy of the 30-day written notice in accordance with (a) above within five days of giving the notice to the client. This requirement is not met as evidenced by:
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Licensee will conduct a training with the Assistant Administrator and Administrator regarding Title 22 Section 80068.5 - Eviction Procedures. Licensee will submit the in-service training document
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Based on interview, record review and observation the licensee did not comply with the section cited wherein the licensee did not inform the Department within 5 days of serving R1 an eviction notice on 10/16/2024 which poses an immediate health, safety and personal rights risk to persons in care.
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to LPA Dolores via email by POC due date of 11/05/2024.
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
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2024


LIC809 (FAS) - (06/04)
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