435202509-11-2-2023-26-AS-KHOS-CZ4KVS-20240102071450

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202509
Report Date: 11/02/2023
Date Signed: 11/02/2023 04:14:20 PM

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
11/01/2023 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20231101121001

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: 25	DATE:	11/02/2023
		UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Nicholas Inneh		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Staff do not properly maintain the facility grounds

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.

On 11/01/2023, the Department received a complaint alleging the staff do not properly maintain the facility grounds. On 11/02/2023, the intial complaint investigation was conducted.

During visit, LPA toured the facility with the Administrator (ADM) to include 15 resident bedrooms, resident bathrooms, 1 shower room, dining room, kitchen, medication room, hallways, and exterior. Based on observation, LPA observed spider webs along the walls and ceiling of the hallways and resident bedrooms. The resident bedrooms were not properly clean and contained dust and dirt along the walls, base boards, windows, and floors of the bedrooms. Resident bedrooms floors contained missing and/or broken tiles. 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: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

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-20231101121001

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: 11/02/2023

NARRATIVE

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LPA observed the floors of the resident’s bathrooms contained dark grey stains and black spots. ADM states the bathroom tiles are old and may be stained. ADM sprayed one of the bathroom floors with a cleaning solution and was unable to wipe off the dirt. ADM was able to remove certain dirt marks surrounding the floor of the toilet. The walls of the bathrooms observed with open patches, dirt and dust.

LPA observed 2 light fixtures that were broken along the hallways.

Based on interview and record review, the Licensee has plans to renovate the facility’s grounds to include (but not limited to) updating all the damaged walls, paint, doors, floors, fence, and parking lot. Licensee is currently in the process of obtaining possible funding from the county to assist with the facility's upcoming renovations. Licensee emailed the letter from the county to LPA Dolores.

The Department has investigated the above allegation and the preponderance of evidence standard has been met, therefore, the above allegation is substantiated.

A deficiency is being cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with Administrator, Nicholas Inneh and a copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

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
11/01/2023 and conducted by Evaluator Christine Dolores

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20231101121001

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: 25	DATE:	11/02/2023
		UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Nicholas Inneh		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Staff do not keep a resident's room free from mold

INVESTIGATION FINDINGS:

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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: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

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-20231101121001

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: 11/02/2023

NARRATIVE

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LPA and ADM entered into 15 resident bedrooms. LPA observed 1 out of 15 rooms had an obvious black marking in the corner of the room. The corner of RM #4 had a black marking next to the resident’s bed. Due to the resident laying in bed sleeping during inspection, LPA was unable to closely observe the black marking in the corner of the room. LPA was unable to determine if the black marking was due to mold, dirt, or cracks in the wood. During the tour of the remainder of the bedrooms, LPA did not observe any obvious mold in the facility.

Based on interview with the Administrator, the Administrator has not observed nor was made aware of any mold growing in the facility. ADM states the black marking may be due to the resident touching that area. LPA advised Administrator to have the corner of RM #4 professionally inspected to ensure the area does not have mold. Administrator stated understanding.

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

No deficiencies were cited per California Code of Regulations, Title 22. Advisory note provided. This report was reviewed with Administrator, Nicholas Inneh and a copy of the report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20231101121001

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: 11/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/03/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will purchase new light fixtures for the facility by 11/03/23. Licensee will go over in-service training with staff regarding proper cleaning. Licensee will submit the completed in-service training document and light
	8 9 10 11 12 13 14	Based on interview, record review, and observation the licensee did not ensure the facility was clean, sanitary and in good repair which poses/posed an immediate health, safety, and personal rights risk to persons in care.	8 9 10 11 12 13 14	fixture receipt to LPA Dolores by POC due date.
	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: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC9099 (FAS) - (06/04)

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