435202509-4-18-2024-26-AS-CDOS-D4FQVD-20240418123012

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202509
Report Date: 04/18/2024
Date Signed: 04/18/2024 12:30:22 PM

Document Has Been Signed on 04/18/2024 12:30 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 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: 24	DATE:	04/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Nicholas Inneh		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual required - 1 year inspection. LPA met with Administrator (ADM), Nicholas Inneh. LPA entered and observed 15 bedrooms, 2 shower rooms, 1 common bathroom, dining room, kitchen, medication room, and exterior. All fire exit routes were free and clear of obstruction. All staff present are fingerprint cleared. Facility temperature maintained between 69 to 71 degrees Fahrenheit. Facility's hot water temperature maintained at 119 degrees Fahrenheit. Resident bedrooms contains lighting, beds, linens, dressers/closet space, and a night stand. LPA observed the facility has additional linens available for the residents. Facility has at least 7 days worth of non-perishables and 2 days worth of perishable foods. Items in the refrigerator and freezer observed covered. LPA advised to place a thermometer inside the refrigerator and freezer to monitor the temperatures to ensure compliance with Title 22 regulations. Fire extinguisher last services on 04/13/2023. Carbon monoxide detectors present throughout the facility. The facility has a scheduled date to service all fire extinguishers and carbon monoxide detectors. Emergency disaster plans and facility exit routes posted at every exit door. Last emergency drill was conducted on April September 2023. Facility was advised. LPA reviewed 6 resident files. LPA observed 2 residents physician's report were dated in 2016 and 2020. 1 residents physician's report was not on file. Administrator was advised. LPA reviewed 6 residents centrally stored medical records and 6 residents P&I money is maintained. 6 residents were interviewed. SEE LIC809-C.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/18/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA reviewed 4 staff files to include 1st aid certification, health screening, TB result, and personnel record. LPA did not observed staff are provided 20 hours of annual training on topics to include but not limited to dementia, postural supports, restricted health conditions, and hospice. Administrator was advised.

Facility did not have an infection control plan available for LPA's review.

LPA requested for the facility's updated LIC500, infection control plan, and liability insurance by 04/19/2024.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-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: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 04/18/2024 12:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87208(a)(12)

Plan of Operation

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (12) The Infection Control Plan pursuant to Section 87470. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review the licensee did not comply with the section cited above by not having the infection control plan available for review during LPAs visit which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2024
	Plan of Correction
1 2 3 4	Licensee will submit a current infection control plan to the Department. Licensee will ensure the infection control plan is maintained in the facility. Licensee will submit a statement of understanding to LPA Dolores via email by POC due date.

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review the licensee did not comply with the section cited above in by not providing at least 20 hours of annual training to staff regarding this section which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2024
	Plan of Correction
1 2 3 4	Licensee will submit a statement of understanding of the section cited above to LPA Dolores by POC due date.

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: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 04/18/2024 12:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review the licensee did not comply with the section cited above by not completing the emergency drills quarterly which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2024
	Plan of Correction
1 2 3 4	Licensee will complete the quarterly emergency drill for each shift. Licensee will submit the quarterly drill and statement of understanding of the section cited above to LPA Dolores by POC due date.

Type B

Section Cited

CCR

87458(a)

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above by 1 out of 6 counts for a resident who did not have a physician's report on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2024
	Plan of Correction
1 2 3 4	Licensee will submit a statement of understanding regarding the section cited above to LPA Dolores by POC due date.

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: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4