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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202500
Report Date: 09/07/2022
Date Signed: 09/07/2022 04:48:26 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/07/2022 04:48 PM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 #3FACILITY NUMBER:
435202500
ADMINISTRATOR:CYRIL INNEHFACILITY TYPE:
735
ADDRESS:144 NORTH 5TH STREETTELEPHONE:
(408) 903-3151
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 42CENSUS: 0DATE:
09/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Cyril InnehTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) David Marrufo conducted a Required - 1 Year visit and met with Administrator Cyril Inneh.

During visit, LPA observed that the facility was enclosed by a fence. Administrator Cyril Inneh stated that on 08/2019, there was a fire at the facility that caused the facility to suspend operations and be closed to residents. Administrator Cyril Inneh states there are no residents currently in the facility.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Administrator Cyril Inneh and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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