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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202473
Report Date: 09/20/2023
Date Signed: 09/20/2023 01:33:04 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/07/2021 and conducted by Evaluator Grace Donato
COMPLAINT CONTROL NUMBER: 26-AS-20210507134443
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:
09/20/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Cyrill InnehTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility staff threatened resident in care
INVESTIGATION FINDINGS:
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On 09/20/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegation. LPA met with Administrator Cyrill Ineh and explained the purpose of today's visit.

Regarding the allegation of facility staff threatened resident in care, it was reported that a staff (S1) threatened to hit a resident (R1) because R1 was trying to grab some stuff in the main kitchen.

Based on interviews, observation and record reviews, residents are not allowed in the main kitchen area. This area is separated by a door and a window where residents can communicate to staff with what they need. When R1 entered and tried to grab some items from the cabinets, R1 was warned by S1 to leave otherwise he/she will be reported. Records and interviews show that R1 does have behaviors such as being instrusive and destructs property.


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
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 2
Control Number 26-AS-20210507134443
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: VILA VICTORIA #1
FACILITY NUMBER: 435202473
VISIT DATE: 09/20/2023
NARRATIVE
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There are occasions where residents get impatient with staff members due to them not being able to fulfill requests right away. Staff were provided training sessions regarding de-escalation.

Therefore, based on the interviews conducted, files reviewed, and information collected, the allegation that staff staff threatened resident in care is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.

Report is reviewed and a copy is provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2