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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202473
Report Date: 03/18/2025
Date Signed: 03/18/2025 05:04:43 PM

Document Has Been Signed on 03/18/2025 05:04 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/
DIRECTOR:		MR. CYRIL INNEHFACILITY TYPE:
735
ADDRESS:393 E. SAN FERNANDO STREETTELEPHONE:
(408) 271-9244
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 23CENSUS: 19DATE:
03/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Cyril InnehTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator (ADM) Cyril Inneh.

During visit, LPA toured the facility inside and out. During visit, LPA toured 12 out of 12 resident bedrooms and observed each bedroom to have working lights and available bedding and clothing storage areas. LPA toured two out of two resident bathrooms. Each bathroom had working lights and available soap and paper towels. The water temperatures in the bathroom sinks were 115 F and 116 F.

LPA toured the kitchen area and food storage areas. LPA observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed there to be a locked closet where cleaning supplies are stored. LPA toured the outside area of the facility and found the outdoor exit to be clear of obstructions. During visit, ADM triggered the smoke/carbon monoxide detector system and it functioned properly when tested. LPA observed the first aid kit and found it to be complete.

LPA reviewed resident records for six residents. Residents R1, R2, and R3 were missing the Safeguard for Property and Valuables Form. LPA reviewed the resident Personal and Incidental Money Logs and found them to be complete. During visit, ADM stated that the Centrally Stored Medication Logs for March had not been updated.

LPA reviewed staff records for six staff. Staff S1 was missing an LIC503 Health Screening Form.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D page for more information. This report was reviewed with ADM 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: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2025
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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Document Has Been Signed on 03/18/2025 05:04 PM - It Cannot Be Edited


Created By: David Marrufo On 03/18/2025 at 04:08 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: 03/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2025
Section Cited

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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:
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(10) A health screening as specified in Section 80065(g). This requirement was not met as evidenced by: Licensee did not ensure that 1 out of 6 reviewed staff records included a LIC503 Health Screening Form, which poses a potential health risk to residents in care.
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Type B
03/25/2025
Section Cited

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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
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medications which is retained for at least one year and includes the following: (A) The name of the client for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy. (F) Expiration date. (G) Number of refills. (H) Instructions, if any, regarding control and custody of the medication.

This requirement was not met as evidenced by: Licensee did not ensure that 6 out of 6 reviewed resident records included a current Centrally Stored Medication and Destruction Record for the month of March, which poses a potential health 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.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/18/2025 05:04 PM - It Cannot Be Edited


Created By: David Marrufo On 03/18/2025 at 04:12 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: 03/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2025
Section Cited

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80070 Client Records: (b) Each record must contain information including, but not limited to, the following: (14) An account of the client's cash resources, personal property, and valuables entrusted as specified in Section 80026.
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This requirement was not met as evidenced by: Licensee did not ensure that 3 out of 6 reviewed resident records included a Safeguard for Property and Valuables Form, which poses a potential persona rights 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.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:David Marrufo
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2025


LIC809 (FAS) - (06/04)
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