435202509-10-27-2022-26-AS-SYIP-CKXP9J-20221107100712

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202509
Report Date: 10/20/2022
Date Signed: 10/27/2022 09:53:10 AM

Substantiated

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
10/13/2022 and conducted by Evaluator Christine Dolores

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20221013105435

FACILITY NAME:	VILA MONTE		FACILITY NUMBER:	435202509
ADMINISTRATOR:	NICHOLAS INNEH		FACILITY TYPE:	740
ADDRESS:	17090 PEAK AVENUE		TELEPHONE:	(408) 500-2693
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	28	CENSUS: 26	DATE:	10/20/2022
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Nicholas Inneh		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Staff do not keep the facility free from pests

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to open the initial complaint investigation. LPA met with Administrator, Nicholas Inneh.

During visit, LPA toured the facility with the Administrator to include the resident bedrooms, hallways, bathrooms, dining room, and storage. LPA interviewed 3 residents and the Administrator (S1). LPA obtained the following records: resident roster and bug treatment log from May 2022 – current day.

LPA and Administrator entered 4 resident bedrooms. LPA and Administrator inspected 4 resident beds for pests to include the insect, bed bugs. LPA and Administrator observed 3 out of 4 resident beds to contain bed bugs. LPA and Administrator observed a bed bug crawling on a resident’s (R2) clothing. Administrator immediately removed the bed bug from R2’s clothing and immediately removed the bedding and linens from 2 out of 3 resident beds. LPA and Administrator observed a bedroom to contain bed bugs on the walls.
SEE LIC9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

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-20221013105435

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 MONTE	FACILITY NUMBER: 435202509
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/20/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/21/2022 Section Cited CCR 80087(a)(1)	1 2 3 4 5 6 7	(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. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee and Administrator will continue weekly treatment for bed bugs and utilize aerosol foggers to treat bed bug infested rooms. Licensee and Administrator will seek professional help if the issue cannot be contained. Licensee will send the plan of correction in writing by POC due date.
	8 9 10 11 12 13 14	Based on interview and observation, the licensee did not ensure to keep the facility free from pests such as the insect, bed bugs, which poses an immediate health, safety, and personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

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
10/13/2022 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20221013105435

FACILITY NAME:	VILA MONTE		FACILITY NUMBER:	435202509
ADMINISTRATOR:	NICHOLAS INNEH		FACILITY TYPE:	740
ADDRESS:	17090 PEAK AVENUE		TELEPHONE:	(408) 500-2693
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY:	28	CENSUS: 26	DATE:	10/20/2022
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Nicholas Inneh		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Facility is not clean

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to open the initial complaint investigation. LPA met with Administrator, Nicolas Inneh.

During visit, LPA toured the facility with the Administrator to include the resident bedrooms, hallway, bathrooms, dining room, and storage.

During tour, LPA observed the facility’s bedrooms, bathrooms, hallways, and dining room to be well-kept. LPA observed the facility’s floor to be well-kept with no sticky surfaces and obvious dirt and debris. Resident beds observed made and bedrooms observed well-kept. LPA observed the facility’s bathrooms to be clean. LPA did not observe the facility to have a foul odor. All fire exit routes and passageways were free and clear of obstruction.

SEE LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

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-20221013105435

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 MONTE	FACILITY NUMBER: 435202509
	VISIT DATE: 10/20/2022

NARRATIVE

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Based on interview, the Administrator states facility staff clean and disinfect multiple times daily and as needed.

The Department has investigated the above allegation. Based on observation and interview, the Department has determined that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

This report was reviewed with Administrator, Nicholas Inneh and a copy of the report will be emailed to the Administrator due to technical difficulties with LPA’s printer.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20221013105435

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 MONTE	FACILITY NUMBER: 435202509
	VISIT DATE: 10/20/2022

NARRATIVE

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LPA and Administrator observed no window screen in 1 out of 4 bedrooms. LPA observed the bedroom window to be open. Administrator states the open window may have resulted in multiple flies entering the bedroom due to the lack of a window screen. Facility has installed 2 fly traps in the bedroom in which LPA observed multiple flies stuck on the fly trap. During visit, Administrator placed a window screen in the bedroom and replaced the fly traps.

LPA interviewed 3 residents. 2 out of 3 residents state to have issues with bed bugs at the facility. 2 out of 3 residents state to have gotten bit by bed bugs at the facility. 1 out of 3 residents state to have seen bed bugs at the facility at least 1 – 2 times. 1 out of 3 residents state to have not gotten bit by a bed bug at the facility.

LPA interviewed S1. S1 states the facility has ongoing issues with bed bugs and treats for bed bugs weekly using store bought treatment. The facility has a procedure for new admissions to include checking all personal belongings that are being brought into the facility and washing certain personal belongings prior to being transferred into the resident’s bedrooms. Facility conducts laundry daily and sheets and linens are washed at least once to twice a week, and when needed.

The Department has conducted an investigation on the above allegation. Based on interviews and observation, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. A deficiency is being cited per California Code of Regulations, Title 22. See LIC 9099-D

This report was reviewed with the Administrator and a plan of correction was developed. A copy of the report and appeal rights will be emailed to the Administrator due to technical difficulties with LPA’s printer.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

LIC9099 (FAS) - (06/04)

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