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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202500
Report Date: 10/22/2024
Date Signed: 10/22/2024 03:49:53 PM

Document Has Been Signed on 10/22/2024 03:49 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/
DIRECTOR:		CYRIL INNEHFACILITY TYPE:
735
ADDRESS:144 NORTH 5TH STREETTELEPHONE:
(408) 903-3151
CITY:SAN JOSESTATE: CAZIP CODE:
95112
CAPACITY: 42CENSUS: 0DATE:
10/22/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Nicholas InnehTIME VISIT/
INSPECTION COMPLETED:
03:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to one of the Licensee, Cyril Inneh’s facilities Vila Monte #435202509. During visit, a case management – other visit was conducted to address the facility’s outstanding licensing fees. LPA met with Nicholas Inneh. Licensee, Cyril Inneh was on the phone to discuss the case management visit.

Based on review of the facility’s Licensing fees as of 10/22/2024, the facility has an outstanding balance of $3,404.00. The annual licensing fees has not been paid for year 2022, 2023 and 2024.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D.

This report was reviewed with Nicholas Inneh and Licensee Cyril Inneh and a copy of the report and appeal rights was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
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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Document Has Been Signed on 10/22/2024 03:49 PM - It Cannot Be Edited


Created By: Christine Dolores On 10/22/2024 at 03:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: VILA VICTORIA #3
FACILITY NUMBER: 435202500

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/23/2024
Section Cited
CCR
80036(a)(c)(e)

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(a) An applicant or a licensee shall be charged fees as specified in Health and safety Code Section 1523.1. … (e) The failure of an applicant or licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license. This requirement is not met as evidenced by:
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Deficiency cleared during visit. Licensee paid the licensing fees today and emailed the receipt to LPA Dolores.
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Based on record review and observation, the licensee did not comply with the section cited above wherein the licensee has not paid licensing fees for year 2022, 2023 and 2024 which poses an immediate health, safety, and personal rights risk to persons 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.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
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