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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202473
Report Date: 03/08/2024
Date Signed: 03/08/2024 02:11:15 PM

Document Has Been Signed on 03/08/2024 02:11 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: 21DATE:
03/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Cyril InnehTIME COMPLETED:
02:30 PM
NARRATIVE
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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 facility inside and out. LPA Marrufo toured the kitchen area and the food storage areas. LPA Marrufo observed a perishable food supply of at least two days and a non-perishable food supply of at least 7 days. LPA Marrufo observed a first aid kit and found it to be complete.

LPA Marrufo toured 12 out of 12 resident bedrooms and observed each bedroom to have available bedding and clothing storage areas as well as functioning lighting. During visit, Administrator Cyril Inneh tested the central smoke and carbon monoxide detection system and the system functioned properly when tested.

LPA Marrufo toured two out of two resident bathrooms and observed there to be functioning lights and available soap and paper towels. The bathroom water temperatures measured at 116 F.

LPA Marrufo toured the outdoor exits and found them to be clear of obstructions.

LPA Marrufo reviewed 5 resident records. 5 out of 5 reviewed resident records had complete and balanced Personal and Incidental Money Logs. During visit, Centrally Stored Medication Logs were not available to be reviewed because the records were kept on a damaged computer and had not been printed. Resident R1's records were missing the Safeguard for Property/Valuables form, Consent Form, Personal Rights Form, and R1's Appraisal/Needs and Services Plan was missing signatures. R2 was also missing a Personal Rights form. During review of records for staff S1-S5, staff S1, S4, and S5 were missing current 1st aid certifications, S1 and S3 were missing Health Screening forms, and S3, S4, and S5 were missing Employee Rights forms. See LIC809-C for more information. Page 1 of 2.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2024
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 4
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: 03/08/2024
NARRATIVE
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An Advisory Note was issued. See LIC9102 for more information.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D pages for more information.

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

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/08/2024 02:11 PM - It Cannot Be Edited


Created By: David Marrufo On 03/08/2024 at 01:44 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: 03/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(7)
80075 Health Related Services (k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Licensee did not ensure that 5 out of 5 reviewed resident records included a Centrally Stored Medication and Destruction Record, which poses a potential safety risk to residents in care.
POC Due Date: 03/15/2024
Plan of Correction
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Licensee agrees to ensure that all residents have a Centrally Stored Medication and Destruction Record in their files and submit copies of Centrally Stored Medication and Destruction Records for residents R1-R5 by POC date.
Type B
Section Cited
CCR
80066(a)(10)
80066 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Licensee did not ensure that 2 out of 5 reviewed staff records included a health screening form, which poses a potential safety risk to residents in care.
POC Due Date: 03/15/2024
Plan of Correction
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Licensee agrees to review all staff records and ensure that all staff, including staff S1 and S3, have a health screening form in their records by POC date. Licensee agrees to submit photocopies of S1 and S3’s health screening forms to CCL by POC date.
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:Sarah Yip
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/08/2024 02:11 PM - It Cannot Be Edited


Created By: David Marrufo On 03/08/2024 at 01:48 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: 03/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
80075 (f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Licensee did not ensure that staff S1, S4, and S5 had current first aid certification in their staff records, which poses a potential safety risk to residents in care.
POC Due Date: 03/15/2024
Plan of Correction
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4
Licensee agrees to submit copies of current first aid certifications for staff S1, S4, and S5 by POC date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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:Sarah Yip
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024


LIC809 (FAS) - (06/04)
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