435202473-9-27-2024-26-AS-KHOS-DAHPKX-20241029112353

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202473
Report Date: 09/27/2024
Date Signed: 09/27/2024 04:52:41 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
08/25/2023 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20230825111800

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:	DATE:	09/27/2024
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Cyril Inneh		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Neglect of care and supervision.
Facility has bedbugs.

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. The Department received a complaint with the above allegations on 08/25/2023. On 08/30/2023, LPA Marrufo conducted an initial complaint investigation visit. On 05/17/2024, LPA Marrufo conducted an additional complaint investigation visit.

LPA Marrufo obtained a copy of R1’s Physician’s Report and Appraisal/Needs and Services Plan. R1’s Physician’s Report is dated 05/15/2015. R1’s Physician’s Report states R1 is able to bathe self, dress self, feed self, and care for his/her own toileting needs. R1’s Appraisal/Needs and Services Plan is dated 06/01/2023. R1’s Appraisal/Needs and Services Plan states R1 is incontinent and “Staff will prompt client to use the bathroom.”

See LIC9099-C for more information. Page 1 of 3.

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 3

Control Number 26-AS-20230825111800

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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On 09/27/2024, LPA Marrufo conducted a telephone interview with R1’s case manager, who stated to have observed ADM and two staff encourage R1 to shower. R1’s case manager stated that R1 has been struggling with maintaining his/her own hygiene. R1’s case manager stated to have observed ADM encourage R1 to maintain his/her hygiene. R1’s case manager stated that R1 will refuse to continue a conversation if R1 is spoken to about maintaining R1’s hygiene.

LPA Marrufo interviewed R1 during visit on 09/27/2024. During interview, R1 stated the staff launder R1’s clothes and bed sheets. R1 stated the staff encourage R1 to shower. R1 stated to not need assistance in the bathroom. R1 stated staff do not provide R1 with soap and shampoo.

LPA Marrufo interviewed ADM Cyril Inneh on 09/27/2024. During interview, ADM stated that staff encourage R1 to shower and have good hygiene. ADM stated R1 is given bars of soap and can borrow bottles of shampoo that the rest of the residents also use. ADM stated staff wash R1’s clothes and bedsheets. During visit, LPA observed the spare bedsheets in a storage area as well as supplies of diapers that ADM stated are for R1 and R1’s roommate.

During visit on 08/30/2023, LPA Marrufo interviewed 8 residents. 8 out of 8 interviewed residents stated to have observed bed bugs.

During visit on 02/12/2024, which was a visit for another complaint investigation at the facility, 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.

See LIC9099-C for more information. Page 2 of 3.

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 3

Control Number 26-AS-20230825111800

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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During visit on 05/17/2024, LPA interviewed 11 residents, 2 staff, and Administrator (ADM) Cyril Inneh. 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.

LPA Marrufo obtained a copy of an invoice from a pest control contractor. The invoice is dated 09/13/2023. The invoice states previous services were conducted on 06/21/2023, 07/23/2023, and 08/10/2023.

Based on information from interviews conducted with staff and residents, 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 3 of 3.

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: 3 of 3