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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202473
Report Date: 04/03/2024
Date Signed: 04/03/2024 07:06:12 PM

Substantiated


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
07/09/2021 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20210709140612
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: 21DATE:
04/03/2024
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Cyril InnehTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Facility does not have hot water
Facility has bed bugs
INVESTIGATION FINDINGS:
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On 4/3/2024, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint inspection. LPA met with Administrator Cyril Inneh and explained the purpose of the visit.

The Department investigated the allegations that facility does not have hot water and has bed bugs and based on observation and interviews, the allegations are substantiated. During the tour of facility bathrooms, the water temperature at the sinks and showers tested at 75 degrees Fahrenheit, and interviews of residents and staff indicate that the facility has bed bugs. No documentation was observed to indicate facility had recent pest control services to eradicate the bed bugs.

Therefore, based on interviews and records review and information collected, the above allegations are
determined to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22
cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

A copy of this report and the Appeal Rights are provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
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 3
Control Number 26-AS-20210709140612
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/04/2024
Section Cited
CCR
80088(3)(1)
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80088 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 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 ...

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Licensee has already a new tank and has been continuously moitoring hot water temp in the facility.
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This requirement was not met when hot water tested at 75 degrees Fahrenheit which is not within the required range.
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Type A
04/04/2024
Section Cited
CCR
90072(a)(2)
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80072 Personal Rights (a)Except for children’s residential facilities, each client shall have personal rights which include...(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
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Licensee consistently monitors and does pest control services every week.
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This requirement was not met when it was reported by multiple residents and staff that the facility has bed bugs and there was no documentation presented that would indicate facility had recent pest control services to eradicate the bed bugs.
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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: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
07/09/2021 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20210709140612

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: 21DATE:
04/03/2024
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Cyril InnehTIME COMPLETED:
12:20 PM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Facility kitchen is dirty
Facility carpets are dirty
Staff did not adequately supervise residents leading to a resident getting into an altercation with another resident
Staff speak inappropriatly to residents in care
INVESTIGATION FINDINGS:
1
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3
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5
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7
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9
10
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On 4/3/2024, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint inspection. LPA met with Administrator Cyril Inneh and explained the purpose of the visit.

The Department investigated the allegations that the kitchen is dirty, facility carpets are dirty, that staff did not adequately supervise residents in care leading to a resident getting into an altercation with another resident, and staff speak inappropriately to residents in care. Based on observation and interviews, there is not a preponderance of evidence to prove or disprove that the allegations occurred or are valid therefore they are unsubstantiated.

No deficiencies were cited during the visit. Report is reviewed and copy is provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3