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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202078
Report Date: 07/19/2022
Date Signed: 07/19/2022 03:50:30 PM

Document Has Been Signed on 07/19/2022 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 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:
07/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Ariel PalenciaTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Administrator Ariel Palencia.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo observed the facility entrance and observed a visitor screening area. LPA Marrufo observed the second floor storage room and observed there to be a PPE supply of at least 30 days, including N95 masks. LPA Marrufo observed a perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days. LPA Marrufo observed 2 out of 2 resident bathrooms and observed there to be available soap and paper towels.

LPA Marrufo toured 7 out of 7 resident bedrooms, dinning room, and outdoor area.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Administrator Ariel Palencia and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2022
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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