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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202473
Report Date: 10/12/2021
Date Signed: 10/13/2021 01:36:22 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/28/2020 and conducted by Evaluator Yatfai Ng
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20200728162031
FACILITY NAME:VILA VICTORIA #1FACILITY NUMBER:
435202473
ADMINISTRATOR:MR. CYRIL INNEHFACILITY TYPE:
735
ADDRESS:393 E. SAN FERNANDO STREETTELEPHONE:
(408) 903-3151
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY:23CENSUS: 22DATE:
10/12/2021
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Cyril InnehTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff not allowing resident to leave the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced subsequent investigation visit to deliver the findings. LPA met with the Administrator Cyril Inneh.

An initial unannounced tele-investigation was conducted by LPA on 08/05/2020. LPA interviewed 1 staff and 1 resident. On 10/19/2020, LPA interviewed 2 staff. On 08/17/2021, LPA conducted an unannounced subsequent complaint investigation. LPA re-interviewed 1 staff and interviewed 8 residents.

Between 08/05/2020and 08/17/2021, 3 staff were interviewed. 3 out of 3 staff denied not allowing resident to leave the facility. Staff only discouraged the residents going out because of the Governor’s shelter-in-place proclamation. Residents were free to go out for essential medical visits.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 26-AS-20200728162031
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: VILA VICTORIA #1
FACILITY NUMBER: 435202473
VISIT DATE: 10/12/2021
NARRATIVE
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Between 08/05/2020 and 08/17/2021, 9 residents were interviewed. 9 out of 9 residents denied they were forced to stay in the facility that they could not leave the facility.

Based on interviews, the department has determined that the allegation was UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

This report was reviewed with Administrator. A copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/28/2020 and conducted by Evaluator Yatfai Ng
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20200728162031

FACILITY NAME:VILA VICTORIA #1FACILITY NUMBER:
435202473
ADMINISTRATOR:MR. CYRIL INNEHFACILITY TYPE:
735
ADDRESS:393 E. SAN FERNANDO STREETTELEPHONE:
(408) 903-3151
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY:23CENSUS: 22DATE:
10/12/2021
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Cyril InnehTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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9
Facility has a bed bug infestation.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced subsequent investigation visit to deliver the findings. LPA met with the Administrator Cyril Inneh..

An initial unannounced tele-investigation was conducted by LPA on 08/05/2020. LPA interviewed 1 staff and 1 resident. On 10/19/2020, LPA interviewed 2 staff. On 08/17/2021, LPA conducted an unannounced subsequent complaint investigation. LPA re-interviewed 1 staff and interviewed 8 residents.

Between 08/05/2020and 08/17/2021, 3 staff were interviewed. 3 out of 3 staff admitted there were bed bugs in the facility.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20200728162031
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: VILA VICTORIA #1
FACILITY NUMBER: 435202473
VISIT DATE: 10/12/2021
NARRATIVE
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Between 08/05/2020 and 08/17/2021, 9 residents were interviewed. 9 out of 9 residents stated they had seen bed bugs in the facility.

Based on interviews, the preponderance of evidence standard has been met; therefore, the allegation is found to be SUBSTANTIATED, which means that the allegation did occur.

A deficiency was cited today as per California Code of Regulations, Title 22. See 9099-D for more information. Failure to correct the deficiencies may result in civil penalties.

This report was reviewed with Administrator. A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20200728162031
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: VILA VICTORIA #1
FACILITY NUMBER: 435202473
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2021
Section Cited
CCR
80087(a)(1)
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80087 Buildings and Grounds: (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
(1) The licensee shall take measures to keep the facility free of flies and other insects.
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Licensee to submit a proof of pest control by POC due date.
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This requirement was not met as evidenced by:
based on interviews: 3 out of 3 staff and 9 out of 9 residents stated there were bed bugs in the facility. This posed a potential health and 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.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5