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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 03:49:39 PM

Document Has Been Signed on 07/12/2022 03:49 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 - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ariel PalenciaTIME COMPLETED:
12:00 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 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.

During visit, LPA Marrufo asked Administrator Ariel Palencia to open the storage room that is near Room 6 in the facility. After opening the door, Administrator Palencia's video feed showed a bed, mattress, and personal items in the storage room. Administrator reported to LPA Marrufo on 10/19/2021 to have received a verbal confirmation from the Fire Marshall that the storage room was not permitted to be used as a bedroom. During today's visit, Administrator Palencia and S1 stated S1 uses the bed in the bedroom during work breaks.

The facility had previously been issued a deficiency citation for using the storage room as a bedroom on 07/22/2021. A second citation along with a $250 civil penalty was issued on 08/03/2021 for having a bed in the storage room.

A deficiency was cited as per California Code of Regulations Title 22. See 809-D for more information.

A repeat civil penalty of $1000 was assessed for a repeated violation within a 12 month period. See LIC421M. If the deficiency is not corrected within 24 hours, an additional $100 per day will be assessed until the deficiency is corrected.

This report was reviewed with Administrator Ariel Palencia and a copy of the report and appeal rights will be sent to him to sign and return 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
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 07/12/2022 03:49 PM - It Cannot Be Edited


Created By: David Marrufo On 07/12/2022 at 01:46 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
85087(a)(3)(A)

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3 No room commonly used for other purposes shall be used as a bedroom for any person. (A) Such rooms shall include but not be limited to halls, stairways, unfinished attics or basements,
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Licensee agrees to remove the bed and other personal belongings from the stockroom and submit photographs to CCL by POC date.
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 garages, storage areas, and sheds, or similar detached buildings. This requirement was not met as evidenced by: Licensee did not ensure that the second floor stockroom was not being used as a bedroom for staff S1, 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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