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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202078
Report Date: 07/14/2022
Date Signed: 07/14/2022 04:04:12 PM

Document Has Been Signed on 07/14/2022 04:04 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 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:
07/14/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Ariel PalenciaTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) David Marrufo, Licensing Program Manager (LPM) Sarah Yip, and Program Clinical Consultant (PCC) Nurse Roxane Fangon conducted a follow-up tele-visit via Zoom to provide technical assistance to prevent and mitigate the spread of COVID-19 at the facility and met with Administrator Ariel Palencia. The visit was a follow-up for the virtual visit that occurred on 07/12/2022.

Adminstrator Ariel Palencia reports that there are currently 0 COVID-19 positive residents and 0 COVID-19 positive staff.

During today's tele-visit, PCC Nurse Roxane Fangon made the following recommendations to the facility:

1. Leave visitor screening form and thermometer by entrance
2. Label container with visitor screening materials to notify staff to return container to small office
3. Administrator should fit test staff for N95 masks, per Cal OSHA regulations


This report was reviewed with with Administrator Ariel Palencia. A copy of the report will be sent to him for it be signed and returned to CCL.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2022
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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