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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202078
Report Date: 07/03/2024
Date Signed: 07/03/2024 05:28:19 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/25/2024 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20240125095725
FACILITY NAME:VILLA 2 RESIDENTIAL CARE HOMEFACILITY NUMBER:
435202078
ADMINISTRATOR:ARIEL PALENCIA YFACILITY TYPE:
735
ADDRESS:204 N. MORRISON AVE.TELEPHONE:
(408) 998-2791
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY:14CENSUS: 12DATE:
07/03/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ariel PalenciaTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Staff provide an unsanitary cup for drinking water
Staff lock living room after 8 PM and use the living room as their bedroom
INVESTIGATION FINDINGS:
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On 07/03/2024, Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Administrator Ariel Palencia.

On 01/25/2024, the Department received a complaint with the above allegations. An initial complaint investigation visit was conducted on 02/01/2024. Throughout the investigation, LPA Marrufo interviewed residents R1-R10 (although R6 refused to be interviewed), staff S1-S3, and the Administrator (ADM) Ariel Palencia, and toured and observed the facility and reviewed facility records.

9 out of 9 interviewed residents stated to have not observed staff provide an unsanitary cup for drinking water.
See LIC9099-C for more information. Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
Control Number 26-AS-20240125095725
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 2 RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202078
VISIT DATE: 07/03/2024
NARRATIVE
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S1 stated to have rewashed and reused Styrofoam cups. S2 stated that if a Styrofoam cup had a drink poured into it and no one used the cup, S2 will pour the drink out of the Styrofoam cup, wash it, and reuse it.

During visit on 02/01/2024, LPA observed two Styrofoam cups in the dishwasher bin and one Styrofoam cup next to the sink with dark soda stains inside that looked like soda had been poured out of the cup.

7 out of 9 interviewed residents stated to have observed staff lock the living room after 8 PM and use the living room as a bedroom. 2 out of 9 interviewed residents stated to have not made that observation.

Staff S1-S3 stated to have observed staff lock the living room after 8 PM and use the living room as a bedroom. Staff S1 stated to have been the staff who locks the living room at 8 PM and uses it as a bedroom. ADM stated during interview that staff S1 locks the living room and uses it as a living room.

Based on interviews and observations, there is preponderance of evidence to prove the alleged violations did occur. Therefore, the allegations are substantiated.

See 9099-D for deficiencies cited per the California Code of Regulations, Title 22.

This report was reviewed with ADM Ariel Palencia and a copy of this report and appeal rights were provided.

Page 2 of 2.

END REPORT
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/25/2024 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20240125095725

FACILITY NAME:VILLA 2 RESIDENTIAL CARE HOMEFACILITY NUMBER:
435202078
ADMINISTRATOR:ARIEL PALENCIA YFACILITY TYPE:
735
ADDRESS:204 N. MORRISON AVE.TELEPHONE:
(408) 998-2791
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY:14CENSUS: DATE:
07/03/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:TIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Due to lack of supervision residents engaged in inappropriate interactions
Staff did not make sure medication were properly stored
Staff falsified documents
Staff refuse to assist residents after 8 PM
INVESTIGATION FINDINGS:
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6 out of 9 interviewed residents stated to have not observed residents engage in inappropriate interactions. R3-R5 stated to have observed residents engage in inappropriate interactions. R3-R5 stated to have observed two male residents get into a physical fight with each other. R3 and R5 stated R6 touches female residents on their breasts. R4 stated to have not observed R6 touch any residents inappropriately.

R3 stated staff evicted the two residents after the fight. R4 stated the staff witnessed the fight and did not do anything to break up the fight. R5 stated staff broke up the fight and separated the residents and sent them to their rooms.

See LIC9099-C for more information. Page 1 of 4.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 26-AS-20240125095725
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 2 RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202078
VISIT DATE: 07/03/2024
NARRATIVE
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Staff S1 and S3 stated to have observed two male residents get into a physical fight with each other. S1-S3 stated to have not observed any resident, including R6, have inappropriate interactions with residents or touch any female resident’s breasts. S1 and S3 stated to have observed two male residents physically fight each other. S3 stated to have observed when two male residents physically fought each other. S1 stated to have not observed the fight but provided first aid to one of the residents afterwards.

ADM stated during interview on 02/01/2024 that ADM has tried to move R6 into a crisis center. ADM stated to have moved R6 into a different bedroom when R6 was making inappropriate advances and contact with resident R11, a former resident of the facility, so that R6 would be farther away from R11.

During an interview on 05/04/2023, which was part of another complaint investigation visit at the facility for a complaint that also involved R1, ADM stated that ADM would talk to R6 and R6’s case managers about R6’s touching of other residents. ADM stated to have been in discussions with R6’s case managers about moving R6 to a crisis residential home. ADM stated R6’s case managers would work to have R6’s medications changed. ADM stated R6 used to see R6’s case managers once a week. ADM stated, however, R6’s case management organization has had staffing issues in the past year, resulting in less frequent meetings between R6 and R6’s case manager. ADM stated to not have records of R6’s meetings with R6’s case managers. ADM stated R6 has consistently visited R6’s psychiatrist each month, except for the 3 months prior to the interview. ADM stated R6 visited R6’s psychiatrist once in the past 3 months. ADM stated the staffing issues at R6’s case management organization have impacted R1’s visit schedule to R6’s psychiatrist.

LPA Marrufo conducted a telephone interview with R6’s Conservator (C1) on 05/03/2024. C1 stated to not know how often R1’s case managers meet with R6 and how often R6 visits R6’s psychiatrist.

LPA Marrufo obtained a copy of resident R6’s Appraisal/Needs and Services Plan. R6’s Appraisal/Needs and Services Plan states R6 “experiences frequent sexual preoccupation with peers and staff, and has repeatedly reported that auditory hallucinations influence these decisions.” The document states R6’s socialization needs are to “maintain and respect boundaries of staff and other residents.” The methods of evaluating R6’s socialization progress is stated as “Staff observations, self-report, weekly meeting with case manager.”

Page 2 of 4.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 26-AS-20240125095725
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 2 RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202078
VISIT DATE: 07/03/2024
NARRATIVE
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The document states R6’s mental needs as “minimize psychiatric symptoms” and the method of evaluating R6’s mental needs progress as “Staff observations, self-report, monthly meetings with psychiatrist.”

Administrator (ADM) Ariel Palencia provided LPA Marrufo with forwarded emails between and R6’s psychiatrist. In an email from 12/08/2023, ADM notified R6’s psychiatrist that ADM will get newly prescribed medication for R6. In another email from 05/03/2024, ADM stated ADM stated R6’s labs were taken the day before and was requesting for R1’s psychiatrist to upload the lab results. Microsoft Teams conference invites were sent in emails from 01/25/2023 and 06/06/2023 between ADM and R6’s behavioral management team. In an email from 08/01/2023, R6’s psychiatrist provided ADM with instructions on how to prepare R6 for labs that were scheduled to occur on 08/15/2023.

LPA Marrufo interviewed R6 on 04/09/2024. During interview, R6 stated that ADM told R6 not to touch people. R6 stated that ADM told R6 not to touch people as recently as a couple days prior to the interview. R6 stated to not remember if ADM told R6 not to touch any particular person.

LPA Marrufo conducted a telephone interview with R6’s Case Manager (CM1) on 05/03/2024. During interview, CM1 stated to have become R6’s case manager three weeks ago. CM1 stated that there have been staffing issues at R6’s case management organization. CM1 stated to have met with R6 once so far. CM1 stated R6 visited R6’s psychiatrist at the end of April.

9 out of 9 interviewed residents and 3 out of 3 interviewed staff stated to have not observed staff not making sure medications were properly stored. Resident R5 stated to have at one time accidentally dropped a pill on the plate of R11, but quickly picked up the medication and consumed the pill. Staff S3 stated to have observed R5 accidentally drop a pill on R11’s plate for “two seconds” and then consumed the medication.

On 02/01/2024, LPA Marrufo toured Rooms 3, 4, and 6 and did not find any unsecured medications. On 07/03/2024, LPA toured Rooms 1, 2, 5, and 7 and did not find any unsecured medications.

R11 stated during interview that ADM falsified the date of R11’s Admission Agreement and falsified R11’s medication logs.

Page 3 of 4.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 26-AS-20240125095725
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 2 RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202078
VISIT DATE: 07/03/2024
NARRATIVE
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ADM stated during interview on 02/01/2024 that ADM signed R11’s Admission Agreement late. ADM stated R11 was admitted on 01/02/2024 and the Admission Agreement was signed on 01/16/2024.

LPA Marrufo obtained a copy of R11’s Admission Agreement and observed the admit date was recorded as 01/02/2024 and the agreement was signed on 01/16/2024.

ADM stated R11’s behavioral health agency did not require ADM to keep a Medication Administration Record (MAR) for R11. ADM stated R11 called ADM and asked when R11 had taken a medication and ADM provided the dates and times ADM believed R11 took the medications. ADM stated R11 then remembered R11 had not taken the medication at the time ADM provided.

9 out of 9 interviewed residents and 3 out of 3 interviewed staff stated to have not observed staff refuse to assist residents after 8 PM. ADM stated during interview that staff assist residents after 8 PM.

Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22

This report was reviewed with ADM Ariel Palencia and a copy of this report was provided.


Page 4 of 4.



END REPORT
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 26-AS-20240125095725
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 2 RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202078
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/04/2024
Section Cited
CCR
80076(a)(13)
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80076 Food Services (a) In facilities providing meals to clients, the following shall apply: (13) All persons engaged in food preparation and service shall observe personal hygiene and food services sanitation practices which protect the food from contamination.
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LIcensee agrees to submit a Plan of Correction by POC date stating how the Licensee will ensure that facility staff will not reuse Styrofoam cups when serving beverages to residents.
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This requirement was not met as evidenced by: Licensee did not ensure that facility staff did not reuse Styrofoam cups during food service to residents, which poses an immediate safety risk to residents in care.
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Type A
07/04/2024
Section Cited
CCR
85087(a)(3)
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Buildings and Grounds: (a) In addition to Section 80087, bedrooms must meet, at a minimum, the following requirements: (3) No room commonly used for other purposes shall be used as a bedroom for any person. This requirement was not met as evidenced
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Licensee agrees to submit a Plan of Correction by POC date stating how the Licensee will ensure that no part of the facility, including the living room, is used as a bedroom for staff or any other person.
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by: Licensee did not ensure that the facility living room was not used by staff as a bedroom, which poses an immediate safety risk to residents 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.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8