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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202509
Report Date: 10/26/2023
Date Signed: 10/26/2023 12:09:14 PM


Document Has Been Signed on 10/26/2023 12:09 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:
10/26/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:NICHOLAS INNEHTIME COMPLETED:
12:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived to the facility unannounced to open an initial complaint investigation. During the complaint investigation, a case management - deficiencies visit was conducted. LPA met with Administrator (ADM), Nicholas Inneh.

During visit, LPA was made aware of a resident (R1) who passed away. Based on interview with ADM, the resident passed away on 10/13/2023. LPA did not observe an incident report and death report was sent to the Department. LPA spoke with the Licensee, Cyril Inneh during visit who states he had faxed the incident report and death report the day after the incident. Licensee was unable to immediately provide the proof of fax during visit.

The following documents were obtained to include the incident report, death report, police case number, R1's physician's report, appraisal/needs and services plan, identification and emergency information, and medical records. Licensee will submit staff's 1st Aid Certification to LPA Dolores by 1:00pm today.

A deficiency was cited per California Code of Regulation, Title 22. See LIC809-D. A civil penalty of $250 will be assessed for a repeat violation within 12 months of the initial citation. If the deficiency is not corrected within 24 hours, an additional $100 will be assessed until the deficiency is corrected. See LIC421FC.

This report was reviewed with Administrator, Nicholas Inneh and a copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
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 10/26/2023 12:09 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: 10/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/27/2023
Section Cited
CCR
87211(a)(1)(A)

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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.This requirement is not met as evidenced by:
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Licensee will submit a plan in writing to ensure incident reports and death reports will be sent to the Department within the reporting requirement, to LPA Dolores by POC due date.
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Based on interview, record review, and observation the licensee did not ensure to inform the Department of a death of a resident within 7 days of the occurrence which poses/posed 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: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
LIC809 (FAS) - (06/04)
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