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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202473
Report Date: 11/20/2024
Date Signed: 11/20/2024 04:59:02 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
02/16/2023 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20230216153147
FACILITY NAME:VILA VICTORIA #1FACILITY NUMBER:
435202473
ADMINISTRATOR:MR. CYRIL INNEHFACILITY TYPE:
735
ADDRESS:393 E. SAN FERNANDO STREETTELEPHONE:
(408) 271-9244
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY:23CENSUS: DATE:
11/20/2024
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Cyril InnehTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility does not have enough food
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Administrator (ADM) Cyril Inneh.

During visit on 09/27/2024, LPA interviewed 3 residents. During today's visit, LPA interviewed 6 residents. 9 out of 9 total interviewed residents stated that there was enough food at the facility and meals are served with large enough portions. During interview on 11/20/2024, ADM stated that food is purchased for the facility twice a month and ADM tells staff to ensure that each resident is served enough food.

During visit on 09/27/2024, LPA observed food service and observed food supplies in the kitchen and pantry areas.

See LIC9099-C for more information. Page 1 of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
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 4
Control Number 26-AS-20230216153147
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: VILA VICTORIA #1
FACILITY NUMBER: 435202473
VISIT DATE: 11/20/2024
NARRATIVE
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Based on information from interviews conducted with staff and residents, and observations, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated.

No Deficiencies were cited under California Code of Regulations Title 22

This report was reviewed with ADM Cyril Inneh and a copy of this report was provided.


Page 2 of 2.



END REPORT
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
02/16/2023 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20230216153147

FACILITY NAME:VILA VICTORIA #1FACILITY NUMBER:
435202473
ADMINISTRATOR:MR. CYRIL INNEHFACILITY TYPE:
735
ADDRESS:393 E. SAN FERNANDO STREETTELEPHONE:
(408) 271-9244
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY:23CENSUS: DATE:
11/20/2024
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Cyril InnehTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
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Facility has roaches
INVESTIGATION FINDINGS:
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During visit on 08/30/2023, LPA Marrufo interviewed 7 residents. 5 out of 7 interviewed residents stated to have observed cockroaches at the facility.

On 11/20/2024, Administrator Cyril Inneh stated to not have pest control invoices from 11/2022 to 02/2023.

Based on records review and interviews, there is preponderance of evidence to prove the alleged violation did occur; therefore, the allegation is substantiated.

See 9099-D for deficiencies as cited per the California Code of Regulations, Title 22.

This report was reviewed with Administrator Cyril Inneh and a copy of this report and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
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 4
Control Number 26-AS-20230216153147
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: VILA VICTORIA #1
FACILITY NUMBER: 435202473
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/21/2024
Section Cited
CCR
80087(a)(1)
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(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 agrees to submit a Plan of Correction by POC date ensuring how measures will be taken to keep the facility free of flies and other insects, including measures such as contracting a pest control company to regularly rid the facility of cockroaches and other insects.
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This requirement was not met as evidenced by: Licensee did not ensure that 5 out of 7 interviewed residents reported to have observed cockroaches at the facility and there was no pest control contracted to keep the facility free of cockroaches, 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.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4