435202509-5-10-2023-26-AS-CDOS-CRPV44-20230510160544

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202509
Report Date: 05/10/2023
Date Signed: 05/10/2023 04:05:57 PM

Document Has Been Signed on 05/10/2023 04:05 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: 26	DATE:	05/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Nicholas Inneh		TIME COMPLETED:	04:15 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 Analysts (LPAs) Christine Dolores and Tracy Pham arrived unannounced to conduct the annual inspection. LPAs met with Administrator, Nicholas Inneh. During visit, LPAs toured the facility with staff to include the kitchen, hallways, resident rooms, bathrooms, shower rooms, and dining room. Bedrooms observed with bedding, linens, lighting, night stands, and dressers. Disinfectants observed secured. LPAs observed the shower room was dirty with orange rust stains on the shower walls and floor. Administrator was advised to ensure the bathing facilities shall be clean and sanitary. LPAs observed staff cooking meals in the kitchen. Facility has 7 days worth of non-perishables and 2 days worth of perishable foods. All foods observed with a lid and labeled. Facility is equipped with a lidded trash bin and fire extinguisher. The fire extinguisher was last serviced on 04/13/2023. Hot water temperature maintained at 120 degrees Fahrenheit. 4 resident records were reviewed to include: physician's report, TB information, appraisal needs and services plan, emergency contact information, consent forms, personal rights, centrally stored medication records destruction log, and safeguard of cash resources. Medications and cash resources observed secured. LPAs observed 1 resident (R1) did not have a TB result on file. It was observed the residents appraisal needs and services plans were not signed. Administrator stated the needs and services plans were recently updated and stated a plan to obtain a signature from the resident and/or responsible party. It was observed the resident's physician's reports were not up-to-date with reports last updated in year 2013 and 2016. Administrator states the resident's doctors see the residents frequently, however, they have not updated the physician's report. Administrator was advised. 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: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

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 05/10/2023 04:05 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: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review, and interview resident (R1)'s medical assessment did not include a TB result which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/11/2023
	Plan of Correction
1 2 3 4	Licensee will submit a plan to ensure resident (R1)'s obtains a TB test to LPA Dolores by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/10/2023 04:05 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: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review licensee did not ensure personnel records were maintained at the facility for review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/17/2023
	Plan of Correction
1 2 3 4	Licensee will submit a written plan to ensure that all personnel records will be maintained at the facility at all times to LPA Dolores by POC due date.

Type B

Section Cited

CCR

87506(a)

Resident Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review licensee did not ensure all needs and services plans were signed and that residents did not obtain an updated physician's report which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/17/2023
	Plan of Correction
1 2 3 4	Licensee will submit a written plan to ensure all resident records will be complete and current to LPA Dolores via email by POC due.

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: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 05/10/2023 04:05 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: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87219(a)

Planned Activities

(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review licensee did not ensure residents were provided activties which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/17/2023
	Plan of Correction
1 2 3 4	Licensee will create an activities list and submit a written plan to ensure residents are provided activtiies. Licensee will submit a plan to LPA Dolores by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

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: 05/10/2023

NARRATIVE

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The facility did not maintain staff records at the facility. Administrator states the Licensee has it stored at another location. LPAs was not able to review any staff records to include first aid certification, training records, and other related personnel records. Administrator was advised.

Facility has an emergency disaster plan. Posters observed to include if you see something say something, ombudsman, personal rights, and other COVID related posters.

5 residents and 4 staff were interviewed during visit. During interview, it was stated the facility did not have activities to provide throughout the day. Administrator was advised.

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 was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023

LIC809 (FAS) - (06/04)

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