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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202078
Report Date: 07/12/2022
Date Signed: 07/12/2022 03:48:41 PM

Document Has Been Signed on 07/12/2022 03:48 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:
07/12/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ariel PalenciaTIME COMPLETED:
12:00 PM
NARRATIVE
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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 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.

Adminstrator Ariel Palencia reports that there are currently 1 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. Place COVID-related signs at entrance for visitors, especially signs advising everyone to wear masks
2. Have a visitor screening area for visitor temperature and symptom checks
3. Do rapid COVID tests for staff returning from travel
4. Have staff take their temperature and check for symptoms each shift.
5. Put signs at front entrance advising residents and visitors to use hand sanitizer and use masks
6. Bathroom needs to be stocked with available soap.
7. Use only liquid soap in the bathroom, not bar soap.
8. Place signs in bathrooms to wash hands for 20 seconds
9. Place trash bin with foot operated lid in bathroom.
10. Keep a 30-day supply of PPEs, including N95 masks, gowns, and face shields
11. Keep all PPE supplies together in a lidded container

See LIC809-C for more information. Page 1 of 2.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: VILLA 2 RESIDENTIAL CARE HOME
FACILITY NUMBER: 435202078
VISIT DATE: 07/12/2022
NARRATIVE
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12. There should be an isolation cart and lidded trash cans by the isolation room.
13. Staff and Administrator should review donning and doffing sequences for PPEs.
14. Administrator should fit test staff for N95 masks, per Cal OSHA regulations
15. Contact Santa Clara County Public Health about the COVID case via SPOT Portal

A follow-up Program Clinical Consultant Virtual Technical Assistance Visit has been scheduled for 07/14/2022 at 3:00 PM.

A deficiency was cited as per California Code of Regulations, Title 22. See LIC809-D for more information.

This report was reviewed with with Administrator Ariel Palencia. A copy of the report and appeal rights 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: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 07/12/2022 03:48 PM - It Cannot Be Edited


Created By: David Marrufo On 07/12/2022 at 01:06 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: 07/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2022
Section Cited
CCR
80064(a)(3)

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80064(a)(3) - Administrator - Qualifications and Duties: (a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation. This requirement was not met as evidenced by: Administrator did not have COVID mitigation policies and
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Licensee agrees to review the latest Provider Information Notices on COVID-19 mitigation policies and implement all the recommendations made in today's report by POC date.
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procedures in place at the facility and expressed lack of awareness of some COVID mitigation procedures, such as proper donning and doffing of PPEs and isolation room procedures, 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.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022


LIC809 (FAS) - (06/04)
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