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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202509
Report Date: 04/19/2022
Date Signed: 04/19/2022 04:20:17 PM


Document Has Been Signed on 04/19/2022 04:20 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:VILA MONTEFACILITY NUMBER:
435202509
ADMINISTRATOR:DONALD WINDHAMFACILITY TYPE:
740
ADDRESS:17090 PEAK AVENUETELEPHONE:
(408) 500-2693
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:28CENSUS: 26DATE:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Nicholas InnehTIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a required 1-year annual inspection to focus on infection control. LPA met with Administrator Nicholas Inneh.

During visit, LPA toured the facility inside and outside to include the hallways, resident rooms, kitchen, bathrooms, storage, and exterior. All fire exit routes were free and clear of obstruction.

Facility observed to have a designated entry point to sign in for all visitors and residents. LPA advised to create a list of COVID-19 symptoms and questions to have at the designated entry point. Hand sanitizer available throughout the facility. Bathrooms observed to be supplied with hygiene products and paper supplies. LPA advised to place hand washing signs in all bathrooms. The following posters were observed to include: symptoms of COVID, social distancing, required mask, and stop the spread of germs. Facility cleans and disinfect multiple times daily and as needed. Facility has a designated visitation area. LPA observed supply of Personal Protective Equipment (PPE) and advised to keep a sufficient amount of PPE supplies in the facility. All staff observed to be wearing a face mask. LPA reviewed facility's policies and procedures to isolation and infection control training. LPA advised to have staff N95 fit tested.

LPA informed the Administrator to review PIN 22-13-ASC and submit Infection Control Plan to CCLD by 06/30/2022.

The following documents were requested to include an updated LIC610E and Administrator Certificate by 04/20/2022. Administrator will send LPA documents for the facility's change of Administrator by 04/29/2022.

No citations were issued per the California Code of Regulations, Title 22. Advisory notes provided.

This report was reviewed with Nicolas Inneh and a copy of this report was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022
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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