435202509-5-28-2025-26-AS-CKAI-DH4PX4-20250528114144

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202509
Report Date: 05/28/2025
Date Signed: 05/28/2025 11:41:55 AM

Document Has Been Signed on 05/28/2025 11:41 AM - 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/ DIRECTOR:	NICHOLAS INNEH		FACILITY TYPE:	740
ADDRESS:	17090 PEAK AVENUE		TELEPHONE:	(408) 500-2693
CITY:	MORGAN HILL	STATE: CA	ZIP CODE:	95037
CAPACITY: 28		CENSUS: 26	DATE:	05/28/2025
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:40 AM
MET WITH:	Nicholas Inneh		TIME VISIT/ INSPECTION COMPLETED:	11:50 AM

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 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 to include the resident bedrooms, hallways, bathrooms, dining room, kitchen, and exterior. 3 staff members present were observed to be fingerprint cleared and associated to the facility. See LIC809-C.

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 05/28/2025

NARRATIVE

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LPA entered into all the resident bedrooms. There were no observation of bed bugs. Staff and 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. LPA observed the facility has completed the cleaning and maintenance log. ADM showed that the pest control company last visited the facility on 05/19/2025. LPA observed bedroom #9 is currently occupied.

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, personal rights, basic medication training, reporting requirements, first aid, emergency procedures, food services, nutrition & hydration, infection control, observing and documenting resident changes, and communication & working with difficult behaviors. Administrator states they continue to implement 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. 1 out of 3 residents is a new admissions to the facility as of March 2025. 3 out of 3 files were completed and up to date. ADM states they do not have any residents with a special diet per the physician.

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 regulations.

During visit, ADM signed the LIC809-D from the annual inspection on 04/24/2025, which was inadvertently amended. A copy of the LIC809-D was provided.

On 05/23/2025, LPA emailed the Licensee and ADM regarding the outstanding civil penalty payment due. This was sent to the Licensee on 10/30/2024. During today's visit, ADM was again reminded of the outstanding civil penalty payment due to the Department.

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

NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025

LIC809 (FAS) - (06/04)

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