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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202473
Report Date: 09/12/2022
Date Signed: 09/12/2022 04:21:14 PM

Document Has Been Signed on 09/12/2022 04:21 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 #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: 23DATE:
09/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Cyril InnehTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Administrator Cyril Inneh.

During visit, LPA Marrufo toured the inside and outside of the facility. LPA Marrufo observed the facility to have a visitor logging area, but it did not include a COVID-19 symptom screening form. The facility had a 30-day supply of PPEs. LPA Marrufo observed a perishable food supply of 2 days and a non-perishable food supply of 7 days. LPA Marrufo observed 2 out of 2 hallway bathrooms to have available soap and paper towels and a hand washing sign. LPA Marrufo toured the outside area of the facility and observed the outdoor exits were free of obstructions.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

An advisory note was issued. See LIC9102 for more information.


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: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2022
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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