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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 01:49:08 PM

Document Has Been Signed on 01/18/2023 01:49 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
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Administrator Cyril Inneh. This is a follow up visit on a complaint that was completed in a separate report. During the investigation, it was determined that staff S1, who was involved in the complaint, admitted to drinking alcohol at home prior to coming to work and then was witnessed at the facility drinking another alcoholic beverage.

Review of facility records indicate that the facility Plan of Operation does not include any requirements for staff to not consume alcohol or drugs prior to or during their working hours at the facility.

A deficiency has been cited as per California Code of Regulations Title 22. This report was reviewed with Administrator Cyril Inneh and a copy of the report was 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 01:49 PM - It Cannot Be Edited


Created By: David Marrufo On 01/18/2023 at 10:28 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
80022(b)(5)

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80022 Plan of Operation: (b) The plan and related materials shall contain the following: (5) Staffing plan, qualifications and duties, if applicable. This requirement was not met as evidenced by: Licensee did not ensure that the facility Plan of Operation included
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Licensee shall submit a plan by POC date to submit a revised Plan of Operation by adding the requirement for staff not to consume alcohol or illegal drugs prior to or during their work hours at the facility. The plan shall also include conducting training with staff regarding not drinking
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requirements for staff not to begin their work shifts having recently consumed alcohol or not consuming alcohol during their working hours at the facility, which poses an immediate safety risk to residents in care.
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alcohol or illegal drugs prior or during a work shift at the facility and submit completed staff training records to CCL once completed.

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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: 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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