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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202509
Report Date: 03/04/2025
Date Signed: 03/04/2025 01:28:19 PM

Document Has Been Signed on 03/04/2025 01:28 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/
DIRECTOR:		NICHOLAS INNEHFACILITY TYPE:
740
ADDRESS:17090 PEAK AVENUETELEPHONE:
(408) 500-2693
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 28CENSUS: 26DATE:
03/04/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Nicholas InnehTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct a case management – legal/non-compliance visit. LPA met with Administrator (ADM), Nicholas Inneh.

The purpose of the visit is to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on 10/23/2024.

LPA discussed the non-compliance plan with the ADM to include ensuring that all staff are trained to provide resident care meeting physical, emotional, and social needs; plan for regular observation from the resident and documentation of resident functioning changes; ensuring the facility is kept clean, safe, sanitary and in good repair, addressing bed bugs proactively and promptly; ensuring all incident and death reports are documented and reported to CCL per Title 22; ensuring all staff obtain a criminal record clearance and association to the facility; ensure all residents medical assessments include a TB result prior to admission; ensure all resident’s reappraisals are updated annually; ensure all meals meet dietary and physician ordered nutritional requirements, and ensuring the Administrator provides proper oversight and administration of the facility operations in alignment with Title 22 regulations.

During visit, LPA toured the facility with Administrator to include all the resident bedrooms, hallways, bathrooms, dining room, kitchen, and exterior. 3 staff members present were observed to be fingerprint cleared. 1 out of 3 staff members was not associated to the facility. During visit, the Licensee immediately associated the staff to the facility via Guardian website. See LIC809-C for additional information.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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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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: 03/04/2025
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LPA entered into all the resident bedrooms rooms with the ADM. There were no observation of bed bugs. ADM states the facility does not have any active cases of bed bugs. LPA observed staff actively cleaning the facility to include the resident bedrooms, bathrooms, and shower rooms during tour of the facility. Based on the facility's non-compliance plan it states that they will maintain a log for cleaning, maintenance, and pest control treatment. ADM states the cleaning and maintenance log has not been implemented yet but states a plan to implement the cleaning and maintenance log, ASAP. LPA observed bedroom #9 (vacant) and the shared bathroom in bedroom #9 was currently being remodeled.

2 staff files (S1 - S2) was reviewed. 2 out of 2 staff were provided training by a certified trainer to include topics of assisting resident with ADLs (activity of daily living), dementia care, and aging. ADM states they review the facility's policy regarding reporting requirements with the staff during the initial orientation. ADM was recommended to document training with the staff regarding topics listed in the non-compliance plan. Administrator stated understanding. Administrator states they have implemented regular check-in with staff every Friday for deep cleaning parts of the facility, monthly meeting with every staff, and daily meeting with the staff as part of their communication.

3 resident files (R1 - R3) was reviewed. 3 out of 3 residents are new admissions to the facility as of December 2024, January 2025, and February 2025. 3 out of 3 files contained a face sheet, TB result, updated appraisal/needs and services plan or the preplacement appraisal, and progress notes.

The Administrator was advised regarding the importance of adhering to the facility's corrective action plan that was developed on 10/23/2024 to ensure the facility's stays within compliance of Title 22 regulation.

No deficiencies were cited per California Code of Regulations, Title 22. Advisory note provided. This report was reviewed with Administrator, Nicolas Inneh and a copy of the report was emailed to the Administrator during visit.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Christine Kabariti
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2025
LIC809 (FAS) - (06/04)
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