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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202509
Report Date: 05/13/2024
Date Signed: 05/13/2024 05:42:16 PM


Document Has Been Signed on 05/13/2024 05:42 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 MONTEFACILITY NUMBER:
435202509
ADMINISTRATOR:NICHOLAS INNEHFACILITY TYPE:
740
ADDRESS:17090 PEAK AVENUETELEPHONE:
(408) 500-2693
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:28CENSUS: DATE:
05/13/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:20 PM
MET WITH:Nicholas InnehTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Christine Dolores and Simi Rai arrived unannounced to conduct a case management visit to follow-up on a visit from 11/02/2023. The visit was regarding an incident that occurred at the facility on 10/12/2023 pertaining to resident (R1). LPAs met with Administrator, Nicholas Inneh.

On 10/12/2023, staff (S1) noticed R1 was choking on food during dinner time. During the investigation, staff members were interviewed. Based on staff interview, it was stated that S1 was facing the TV during dinner time. S1 initially heard someone say something but ignored it at first, as S1 thought it was nothing. The second time, a resident yelled out for help as R1 was choking on food. S1 immediately performed CPR.

See LIC809 on 01/16/2024 for additional information.

A deficiency was 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 was provided.

SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2024
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 05/13/2024 05:42 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: 05/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/14/2024
Section Cited
CCR
87411(a)

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(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement is not met as evidenced by:
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Licensee will provide staff training with emphasis in supervision. Licensee will submit the training document via email to LPA Dolores by POC due date.
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Based on interview, record review, and observation staff (S1) was not competent in providing proper supervision during dinner time by having his/her back turned towards the residents and initially ignoring the resident the first time when R1 began to choke, 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 YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2024
LIC809 (FAS) - (06/04)
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