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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202509
Report Date: 05/10/2023
Date Signed: 05/10/2023 01:02:56 PM


Document Has Been Signed on 05/10/2023 01:02 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:
05/10/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Nicholas InnehTIME COMPLETED:
01:05 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Christine Dolores and Tracy Pham arrived unannounced to open the initial complaint investigation. During visit, LPAs observed deficiencies in which a case management - deficiencies visit was conducted. LPAs met with Administrator, Nicholas Inneh.

Upon arrival to the facility, LPAs was greeted at the front door by staff (S1). Based on review of the facility's staff roster, the individual was not associated to the facility. LPA reviewed Guardian and observed S1 is fingerprint cleared. LPAs reviewed the staff schedule and roster and did not observe 3 other staff members associated to the facility. The 3 staff members were not present during visit nor was scheduled to work today. Administrator was advised to submit the LIC9182 or LIC9188 to associate the staff members to the facility, ASAP. Administrator was advised that the staff members should not be working in the facility until associated. Administrator stated understanding.

During interview, LPAs was informed by the Administrator that a resident (R1) was sent out to the hospital for medical treatment and later passed away in the hospital about 2 weeks ago. The individual was still a resident at the facility. The review of the facility's incident reports did not show a death report or incident report was submitted. Administrator verbally confirmed a death report and incident report was not submitted to the Department. LPA Dolores advised the Administrator of Title 22 regulations on reporting requirements.

Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500), for staff (S1) working at the facility without association. See LIC421BG.

Exit interview was conducted with Administrator, Nicholas Inneh and a copy of the report was provided along with the appeal rights.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (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 01:02 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/11/2023
Section Cited

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or ... This requirement is not met as evidenced by:
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Licensee will submit the LIC9182 or LIC9188 to the Department, ASAP. Licensee will submit a plan to ensure all staff are fingerprint cleared and associated to the facility prior to starting work to LPA Dolores via email by POC due date.
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Based on record review, interview, and observation the Licensee did not comply with the section cited above for staff (S1) working in the facility without association which poses an immediate health, safety, and personal rights risk to persons in care.
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Type A
05/11/2023
Section Cited

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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, … : (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. … (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility.
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Licensee will submit the death report and incident report to LPA Dolores via email by POC due date. Licensee will also send a written plan to ensure complaince to LPA Dolores by POC due date.
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Based on record review, interview and observation the licensee did not ensure to submit an incident report and death report for a resident (R1) who was sent to the hospital for medical treatment and who later passed away 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: 05/10/2023
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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