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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202473
Report Date: 01/18/2023
Date Signed: 01/18/2023 01:43:47 PM

Document Has Been Signed on 01/18/2023 01:43 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:
01/18/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Cyril InnehTIME COMPLETED:
02:30 PM
NARRATIVE
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LPA Marrufo conducted an unannounced Case Management visit and met with Administrator Cyril Inneh. The purpose of the visit was to cite the facility for having staff that are not background cleared or associated.

Staff S1-S4 are not associated to the facility. Staff S5-S6 do not have background clearances.

Deficiencies were cited during today’s visit. See LIC 809-D for more information.

A civil penalty is being assessed in the amount of $3000 for 6 staff (S1 to S6) working at the facility either without fingerprint clearances or without association.

This report was reviewed with Cyril Inneh and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2023
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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Document Has Been Signed on 01/18/2023 01:43 PM - It Cannot Be Edited


Created By: David Marrufo On 01/18/2023 at 09:37 AM
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: 01/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/19/2023
Section Cited
CCR
80019(e)(1)

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80019 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption
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Staff S5-S6 were immediately dismissed from work and will not return until fingerprint clearances have been obtained. Licensee agreed to submit a plan in writing to ensure all new staff are fingerprint cleared and associated to the facility by POC date.

Civil penalty in the amount of $1000 was assessed during visit.
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as required by the Department…This requirement was not met as evidenced by: Based on record review, staff S5-S6 have no criminal record clearances, which poses an immediate threat to residents in care.
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Type A
01/19/2023
Section Cited
CCR80019(e)(2)

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80019 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as
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Staff S1-S4 were immediately dismissed from work and will not return until associations have been obtained. Licensee agreed to submit a plan in writing to ensure all staff are associated to the facility by POC date. Licensee will ensure that documents necessary for
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specified in Section 80019(f)…This requirement was not met as evidenced by: Based on record review, staff S1-S4’s clearances were not transferred or associated to the facility, which posed an immediate safety risk to residents in care.
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transferring and associating staff are sent to the Department by end of day.

Civil penalty in the amount of $2000 was assessed during visit.
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: 01/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2023


LIC809 (FAS) - (06/04)
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