<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
435202473
Report Date:
09/07/2022
Date Signed:
09/07/2022 04:49:11 PM
Document Has Been Signed on
09/07/2022 04:49 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:
VILA VICTORIA #1
FACILITY NUMBER:
435202473
ADMINISTRATOR:
MR. CYRIL INNEH
FACILITY TYPE:
735
ADDRESS:
393 E. SAN FERNANDO STREET
TELEPHONE:
(408) 271-9244
CITY:
SAN JOSE
STATE:
CA
ZIP CODE:
95112
CAPACITY:
23
CENSUS:
23
DATE:
09/07/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
04:50 PM
MET WITH:
Cyril Inneh
TIME COMPLETED:
04:55 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) David Marrufo conducted a case management report to notify the Administrator Cyril Inneh that staff S1 has been delivered an Exclusionary Order by the Department.
Administrator Cyril Inneh confirmed to have received the Exclusionary Order for S1 and S1 is no longer working at the facility.
No deficiencies were cited at this time as per California Code of Regulations Title 22.
This report was reviewed with Administrator Cyril Inneh and a copy of the report was provided.
SUPERVISORS NAME
:
Sarah Yip
LICENSING EVALUATOR NAME
:
David Marrufo
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/07/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/07/2022
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
1