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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202473
Report Date: 08/30/2023
Date Signed: 08/30/2023 04:02:06 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/16/2023 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20230216153147
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:
08/30/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Brandon InnehTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility does not maintain hot water temperature
Facility is not in good repair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Brandon Inneh, staff.

On 02/16/2023, the Department received a complaint with the above allegations. On 02/24/2023 and 07/26/2023, the Department conducted complaint investigation visits.

During visit on 02/24/2023, LPA Marrufo checked the water temperature of the sinks in the second floor bathroom and observed the temperatures to be 108 F and 114 F. During that visit, the first floor bathroom was locked and LPA could not enter.

On today's visit, LPA Marrufo checked the first floor bathroom and observed that the sink would not pour water when the knob was turned towards the left, which is the side designated for hot water. See LIC9099-C for more information Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 26-AS-20230216153147
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/30/2023
NARRATIVE
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The water temperature that poured when the knob was turned to the right, the cold side, was measured at 77 F.

During today's visit, LPA Marrufo observed that the bottom door of the kitchen was off its hinges and placed to be leaning on the doorway. The laundry room had three holes in the ceiling. The first floor bathroom had broken tile on the floor. Resident R1's bedroom had three holes in the wall and the bottom half of the closet door was torn off. 1 out of 2 second floor bathroom sinks was clogged.

Based on LPA observations, there is preponderance of evidence to prove the alleged violations did occur; therefore, the allegations are substantiated.

See 9099-D for deficiencies cited per the California Code of Regulations, Title 22.

This report was reviewed with Brandon Inneh and a copy of this report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 26-AS-20230216153147
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2023
Section Cited
CCR
80088(e)((1)
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80088(e)(1) Furniture, Fixtures, Equipment, and Supplies: (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to
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Licensee agrees to submit a plan to CCL by POC date to fix the first floor bathroom sink so that it can pour water between 105 F and 120 F. Once the sink is repaired, the Licensee shall submit photographic evidence of corrected water temperature from sink to CCL.
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automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement was not met as evidenced by: Licensee did not ensure the first floor bathroom sink has water temperature from 105 F to 120 F, which poses an immediate safety risk to residents in care.
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Type A
08/31/2023
Section Cited
CCR
80087(a)
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80087(a) Buildings and Grounds: (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by: Licensee did not ensure
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Licensee agrees to submit a plan by POC date to repair the damages to the facility cited in this report. Once repairs are made, Licensee shall submit photographic evidence of repairs as well as invoices of repair costs to CCL.
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that the facility did not have walls and ceilings with holes, broken doors and tiles, and a clogged sink, which poses an immediate safety 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.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4