<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202509
Report Date: 01/16/2024
Date Signed: 01/16/2024 02:41:17 PM


Document Has Been Signed on 01/16/2024 02:41 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: 26DATE:
01/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Nicholas InnehTIME COMPLETED:
02:45 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 at the facility 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). LPA met with Administrator, Nicholas Inneh.

On 10/26/2023, LPA Dolores visited the facility unannounced and was made aware of a resident (R1) who passed away.

Based on investigation, it was found that on 10/12/2023, staff noticed R1 was choking on food during dinner time. Staff immediately called 911 and began CPR and First Aid (Heimlich Maneuvers) until the paramedics arrived. R1 was transported to the hospital and pronounced deceased on 10/13/2023.

Based on record review, R1’s cause of death was due to lack of oxygen to the brain from choking on food. It was also noted that R1 had a throat condition.

Based on staff interview, for dinner that night R1 was served a chicken burrito that was cut into three pieces by the staff. R1 was provided a regular diet. It was stated by staff that R1 has had a history of choking on food. Prior to R1’s passing, staff did observe something in R1’s throat. The observation was stated to be brought to the attention of the Administrator. The staff also informed R1’s doctor, however, R1’s doctor did not provide a change of order to R1’s diet. Based on review of records, there is no documentation of the staff’s observation regarding R1’s throat condition. There is also no documentation that R1 was seen by the doctor in the year 2023 regarding R1’s throat condition.

SEE LIC809-C.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024
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 3


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: 01/16/2024
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
The review of R1’s records showed that R1 was at the hospital in October 2020, and it was noted R1 was diagnosed with a throat condition. In the discharge summary, it was noted there was an order for small portions. Based on interview, it was stated that during that time, R1 was being fed a regular diet.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D.

An immediate civil penalty of $500.00 is being assessed against the facility today for violation resulting in the death of a resident in care. An additional Civil Penalty for a violation resulting in the death of a resident is pending review.

A plan of correction was developed with the Administrator, Nicholas Inneh. A copy of the report and appeal rights were also provided to the Administrator, Nicholas Inneh.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/16/2024 02:41 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: 01/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
01/17/2024
Section Cited
CCR
87466

1
2
3
4
5
6
7
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will provide an in-service training to all the staff regarding observations of the residents and proper documentation regarding any changes in condition.
8
9
10
11
12
13
14
Based on interview, record review and observation the licensee did not ensure to document the observation of resident (R1)’s throat condition resulting in R1’s death after choking on food which poses/posed an immediate health, safety, and personal rights risk to persons in care.
8
9
10
11
12
13
14
Licensee will submit the in-service training to LPA by POC due date of 01/17/2024.
Deficiency Dismissed
Type A
01/17/2024
Section Cited
CCR87555(b)(10)

1
2
3
4
5
6
7
(b) The following food service requirements shall apply: (10) Where indicated, food shall be cut, chopped or ground to meet individual needs. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will provide an in-service training with all the staff on portion sizes and reviewing physician's orders / discharge summaries relating to residents special diets.
8
9
10
11
12
13
14
Based on interview, record review, and observation the licensee did not ensure to cut R1’s foods into small portions as indicated on his/her medical discharge summary which poses/posed an immediate health, safety, and personal rights risk to persons in care.
8
9
10
11
12
13
14
Licensee will submit the in-service training to LPA by POC due date of 01/17/2024.
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: 01/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3