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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202473
Report Date: 07/26/2023
Date Signed: 07/26/2023 02:33:07 PM

Document Has Been Signed on 07/26/2023 02:33 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: 22DATE:
07/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator Cyril InnehTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced Required 1 Year inspection visit. LPA met with Administrator, Cyril Inneh.

LPA toured the entire residential facility inside and out. The residential care facility has 3 levels. While touring the facility from top to bottom, LPA observed several areas throughout the facility where dry wall was missing and damaged. LPA observed the third floor bedroom on the left, had a closet door that was damaged. The damaged door was missing the bottom right side. ADM stated that door has been damaged since the beginning of the year. LPA also observed broken dry wall in the second floor bedroom, located on the bathrooms left side. LPA also inspected the facility's bathrooms. LPA observed damage in the bathrooms flooring and grout in the second and first floor bathrooms. While touring the laundry area, which is directly next to the first floor bathroom, LPA observed damaged/ missing dry wall in the ceiling of the laundry area. (LPA also observed an unattended laundry detergent in the laundry area.) ADM stated the damaged areas was due to a leak. ADM stated he is currently working with contractor to address problem areas and is scheduled to have them addressed by the middle of August. ADM stated he will send contact to LPA by August 2, 2023 Note; deficiency was not cited for physical plant due to similar issue being brought up in complaint.

LPA also toured the Common area, dining and kitchen area were observed. Two day supply of perishable and 7 day supply of non-perishable food were observed to be sufficient. Facility bathroom sinks wear measured and ranged from 116-118 degrees F. Smoke and carbon monoxide detectors, fire alarm system(last tested on (06/22/23), and 3 fire extinguishers were observed in the residential facility(last inspection 04/06/2023). Outside area is free of obstruction. LPA asked ADM to provide the last Fire drill/Earthquake drill. ADM stated they conducted the drills but do not have a log.
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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/26/2023
NARRATIVE
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3 Staff records and 3 client records were reviewed. 3 client's medications and medication logs were also reviewed. P&I money was audited with Administrator. 2 Facility staff and 3 residents were interviewed.

Deficiencies cited during today's inspection. See lic809D. Appeal rights were provided Exit interview conducted

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/26/2023 02:33 PM - It Cannot Be Edited


Created By: Manuel Monter On 07/26/2023 at 02:02 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: VILA VICTORIA #1
FACILITY NUMBER: 435202473

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed lauandry detergent acsessilbe to clients in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2023
Plan of Correction
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ADM stated he will have staff meeting regarding toxics and storage and will have staff who attend meeting sign. ADM will send LPA itinerary by poc date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/26/2023 02:33 PM - It Cannot Be Edited


Created By: Manuel Monter On 07/26/2023 at 02:02 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: VILA VICTORIA #1
FACILITY NUMBER: 435202473

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. ADM stated he does conduct drills but does not have a log documenting the drills, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2023
Plan of Correction
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ADM stated he will conduct a fire/ earthquake drill and send a copy to LPA by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023


LIC809 (FAS) - (06/04)
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