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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202078
Report Date: 07/17/2024
Date Signed: 07/17/2024 12:21:06 PM

Document Has Been Signed on 07/17/2024 12:21 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/
DIRECTOR:		ARIEL PALENCIA YFACILITY TYPE:
735
ADDRESS:204 N. MORRISON AVE.TELEPHONE:
(408) 998-2791
CITY:SAN JOSESTATE: CAZIP CODE:
95126
CAPACITY: 14CENSUS: 12DATE:
07/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Ariel PalenciaTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator (ADM) Ariel Palencia.

During visit, LPA toured the facility inside and out. The facility kitchen area and food storage areas had a perishable food supply of at least two days and a non-perishable food supply of at least seven days. The cleaning supplies and knives were kept in the locked kitchen area.

LPA toured the facility and tested the carbon monoxide detector and the smoke detectors in each resident room, hallways, and living room areas. Each smoke detector and the carbon monoxide detector functioned properly when tested.

LPA toured the outside area and found it to be clear of obstructions. Two out of two bathrooms were toured and each bathroom had working lights and available soap and paper towels. The bathroom sink water temperatures were 119 F and 114 F.

LPA reviewed the Personal and Incidental Money Logs for 3 out of 3 residents for whom the facility safeguards money. 3 out of 3 Personal and Incidental Money Logs were balanced during review. LPA Marrufo reviewed the Centrally Stored Medication and Destruction Record (CSMDR) for 5 out of 5 residents and each CSMDR was complete. LPA Marrufo reviewed resident records for residents R1-R5 and each reviewed resident record was missing a Safeguard for Property and Valuables Form. Resident R1 only had the first page of the LIC602 Physician's Report. LPA reviewed staff records for staff S1-S5. Staff S1 and S4 were missing current first aid certifications. Staff S1 was missing an LIC501 Personnel Record. Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D page for more information. An Advisory Notes were issued. See LIC9102s for more information. This report was reviewed with ADM Ariel Palencia and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2024
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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Document Has Been Signed on 07/17/2024 12:21 PM - It Cannot Be Edited


Created By: David Marrufo On 07/17/2024 at 12:01 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 2 RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202078

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
80075 Health Related Services (f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Licensee did not ensure that staff S1 and S4 have current first aid certifications, which poses a potential safety risk to residents in care.
POC Due Date: 07/24/2024
Plan of Correction
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Licensee agrees to submit copies of staff S1 and S4’s current first aid certification to CCL by POC date.
Type B
Section Cited
CCR
80070(b)(14)
(b) Each record must contain information including, but not limited to, the following: (14) An account of the client's cash resources, personal property, and valuables entrusted as specified in Section 80026.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Licensee did not ensure that residents R1-R5 had Safeguard for Property and Valuables forms in their resident records, which poses a potential personal rights risk to residents in care.
POC Due Date: 07/24/2024
Plan of Correction
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Licensee agrees to submit copies of resident R1-R5’s signed and completed Safeguard for Property and Valuables form to CCL by POC date as well as completing an audit of all other resident records and ensuring that all residents have a signed and completed Safeguard for Property and Valuables form in their resident record.
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:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024


LIC809 (FAS) - (06/04)
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