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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202473
Report Date: 09/27/2024
Date Signed: 09/27/2024 04:42:59 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/05/2024 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20240205101243
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: 18DATE:
09/27/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Cyril InnehTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility is dirty
Facility staff does not assist residents with their toileting needs
Resident did not receive right dose of medication
Resident was unlawfully evicted
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Administrator (ADM) Cyril Inneh. On 02/05/2024, the Department received a complaint with the above allegations. On 02/12/2024, LPA Marrufo conducted an initial complaint investigation visit. On 05/17/2024, LPA interviewed 11 residents, 2 staff, and Administrator (ADM) Cyril Inneh. LPA also obtained copies of resident and facility records.
11 out of 11 interviewed residents stated that the facility staff keep the facility clean. 2 out of 2 interviewed staff and ADM stated that that facility staff keep the facility clean. During visit on 05/17/2024, LPA Marrufo toured the facility. LPA did not observe any signs of filth or dirt in the bathroom and shower on the ground floor. LPA observed the upper floor sink, showers, and toilets to be clean, except for coffee that was spilled into one of the sinks. LPA observed the facility supply storage areas and observed cleaning supplies including bottles of multipurpose cleaner, bleach, dish detergent, mops, and other cleaning supplies. LPA observed a wall in the kitchen with postings of staff duties and responsibilities for shifts between 7:00 AM – 3:00 PM, 9:00 AM – 5:00 PM, 3:00 PM – 11:00 PM, and 11:00 PM – 7:00 AM. Each shift has instructions to clean the facility. See LIC9099-C for more information. Page 1 of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
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 5
Control Number 26-AS-20240205101243
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 #1
FACILITY NUMBER: 435202473
VISIT DATE: 09/27/2024
NARRATIVE
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4 out of 11 interviewed residents stated that the staff assist residents with toileting needs. 3 out of 11 interviewed residents stated to not know if staff assist residents with their toileting needs. 4 out of 11 interviewed residents stated that no residents at the facility need assistance with toileting.

2 out of 2 interviewed staff and ADM stated that no residents need assistance with toileting.

R1’s Physician’s Report states R1 can care for R1’s own toileting needs.

2 out of 2 staff and ADM stated R1 did not need assistance with toileting prior to R1’s foot amputation at the hospital.

11 out of 11 interviewed residents stated that the staff provide the right dose of medications. 2 out of 2 interviewed staff and ADM stated that staff provide the right dose of medications.

During interview on 05/17/2024, ADM stated that R1 was not given an eviction notice. ADM stated R1 was sent to the hospital to have a foot amputated. ADM stated that when paramedics brought R1 back to the facility, ADM told the paramedics that the facility is for fully ambulatory residents only. ADM stated to have told the paramedics that ADM has another licensed facility that is non-ambulatory and that R1’s parent is aware about the difference in ambulatory status between both facilities. ADM stated R1 was sent back to the hospital from the facility the same day paramedics returned R1. ADM stated that R1 is still at a skilled nursing facility and a bed is still being held for R1 at the facility.

LPA obtained copies of payments made by R1’s parent to the facility for the months of 03/2024-05/2024. LPA obtained a copy of the facility license, which states the facility is for “All Ambulatory.” LPA Marrufo made one attempted telephone call to R1’s family member on 09/26/2024 at 3:00 PM and two additional attempted telephone calls on 09/27/2024 at 11:13 AM and 2:01 PM. LPA made an attempted telephone call to R1’s Responsible Person on 09/24/2024 and 09/27/2024, but the telephone number was disconnected. Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22. This report was reviewed with Administrator Cyril Inneh and a copy of this report was provided. Page 2 of 2.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/05/2024 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20240205101243

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: DATE:
09/27/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Cyril InnehTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility has bed bugs
INVESTIGATION FINDINGS:
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10 out of 11 interviewed residents stated that there are bed bugs at the facility. 1 out of 11 interviewed residents stated to not observe bed bugs in the facility. 2 out of 2 interviewed staff and ADM stated to have observed bed bugs at the facility. 2 out of 2 interviewed staff stated that the staff spray for bed bugs at the facility. ADM stated that the last contracted pest control invoice is from September 2023. ADM stated the facility staff have been spraying for bed bugs on their own since September because ADM was unhappy with the job done by the previously contracted pest control company. During visit on 05/17/2024, ADM stated that a new pest control contractor will be coming to the facility to treat for bed bugs within two weeks. During visit on 02/12/2024, LPA Marrufo toured the facility. During the tour, LPA observed 8 resident bedrooms. LPA observed bed bugs in 3 out of 8 of the observed bedrooms. During visit on 05/17/2024, LPA Marrufo observed the facility supply storage areas and observed bottles of insect killer.

See LIC9099-C for more information. Page 1 of 2.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
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 5
Control Number 26-AS-20240205101243
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 #1
FACILITY NUMBER: 435202473
VISIT DATE: 09/27/2024
NARRATIVE
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Based on records review, interviews and observations there is preponderance of evidence to prove the alleged violation did occur; therefore, the allegation is substantiated. See 9099-D for deficiencies cited per the California Code of Regulations, Title 22.

This report was reviewed with Administrator Cyril Inneh and a copy of this report was provided.

Page 2 of 2.

END REPORT.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20240205101243
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 #1
FACILITY NUMBER: 435202473
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/28/2024
Section Cited
CCR
80087(a)(1)
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80087 (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.
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Licensee agrees to submit a Plan of Correction to CCL by POC date stating how the licensee will develop a plan to keep the facility free of insects, including bed bugs.
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This requirement was not met as evidenced by: Licensee did not ensure that measures were taken to keep the facility free of flies and other insects, which poses an immediate safety risk to residents in care.
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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: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5