435202473-9-21-2023-26-AS-KHOS-CW8HJ5-20231002061347

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202473
Report Date: 09/20/2023
Date Signed: 09/21/2023 07:57:06 AM

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
11/06/2020 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20201106152544

FACILITY NAME:	VILA VICTORIA #1		FACILITY NUMBER:	435202473
ADMINISTRATOR:	MR. CYRIL INNEH		FACILITY TYPE:	735
ADDRESS:	393 E. SAN FERNANDO STREET		TELEPHONE:	(408) 271-9244
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95112
CAPACITY:	23	CENSUS: 22	DATE:	09/20/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Cyrill Inneh		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Resident was physically abused on numerous occasions by another resident at the facility
Facility staff threatened resident
Facility does not provide a safe environment for resident

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 allegations. LPA met with Administrator Cyrill Ineh and explained the purpose of today's visit.

Regarding the allegation that resident (R1) has been physically abused on numerous occasions by another resident (R2) at the facility, it was reported that R1 has been abused by R2 by hitting him/her on several occassions.

Based on interviews and record reviews, R1 has schizophrenia and is manic and becomes emotionally charged. LPA interviewed the administrator and he stated that R1 does report R2 but only saying to tell R2 to stop bothering him/her. Aside from these no other incidents were reported or happened in the facility. As for R2, resident is very affectionate and staff always remind him/her of boundaries to consider.

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)

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Control Number 26-AS-20201106152544

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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If any altercations happens between two residents or a staff member, Admin addresses behaviors of residents by contacting both case managers if its between two residents, get the story from both sides, have a sit down meeting to discuss behaviors for both parties.

Regarding the allegation that facility staff threatened resident, it was reported that R1 was threatened by staff members by calling law enforcement since R1 doesn't want to re-enter facility.

Based on interview, there is no record or any report regarding staff threatening R1. Based on residents records, R1 has schizo affective disorder which would cause some delusions. Administrator mentioned that sometime R1 says that he/she wants to do like not coming back to the facility. Staff just explains that they need to come back and R1 does come back.

Regarding the allegation that facility does not provide a safe environment for resident, it was reported that R1 has been abused by R2 and threatened by staff therefore not providing a safe environment.

Based on interviews, Administrator stated that there are no complaints or reports about any residents not feeling safe in the facility. Administrator also stated that R1 & R2 both have adjusted to life in the facility and are also independent, meaning they can leave the facility unattended.

There were no medical reports or police reports regarding the cases for these allegations. It might be that the R1 might have signed out from facility and went to an urgent care to have a check up. Facility won't have any records since the resident has signed out and facility doesn't have control as to what activities resident do outside.

Therefore, based on the interviews conducted, files reviewed, and information collected, the allegations that resident was physically abused on numerous occasions by another resident at the facility, staff threatened resident and facility does not provide a safe environment for resident are 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)

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