435202509-11-9-2024-26-AS-KHOS-DB6RPH-20241119121157

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202509
Report Date: 11/09/2024
Date Signed: 11/09/2024 12:48:38 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/01/2023 and conducted by Evaluator Arielle Pascua

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20230501121143

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: 25	DATE:	11/09/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Nicholas Inneh		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Staff failed to prevent resident from being harmed by another resident
Staff failed to safeguard resident's money

INVESTIGATION FINDINGS:

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On 11/09/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA met with staff and explained the purpose of the visit. LPA learned that the Facility Designated Administrator (FDA) was unable to visit the facility at this time, however, LPA was able to contact FDA via phone and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above.

Current Census was 25. A brief interview with FDA Inneh was conducted.
Allegation: Staff failed to prevent resident from being harmed by another resident.
It was alleged that the staff failed to prevent resident from being harmed by another resident. During the course of this investigation, LPA conducted interviews and reviewed facility documentation. Based on interviews conducted it was learned that the facility conducted an internal investigation and found that there was no incident that involved R1 and R2 that was reported to the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20230501121143

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: VILA MONTE	FACILITY NUMBER: 435202509
	VISIT DATE: 11/09/2024

NARRATIVE

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An interview with R1 was conducted regarding this incident and LPA was unable to obtain additional information due to the lapse in time from the time of the incident to the visit conducted on 10/12/2024. An interview with 6 residents were conducted. 6 out 6 residents state that they have not been harmed by another resident or have seen any staff harm other residents around them. Based on records review, it was found that R2 has history of aggressive behavior however was not found to hurt other residents at the time of their residency at the facility. Based on the information gathered, it is unclear if the facility failed to prevent resident from being harmed by another resident.

Allegation: Staff failed to safeguard resident’s money.

It was alleged that the facility staff failed to safeguard resident’s money. During the course of the investigation, LPA conducted interviews and reviewed facility documentation. Based on interviews conducted it was learned that that facility does not currently manage any resident funds. It was found that many residents obtain Payee services in which they received their own money via mail or through debit services. A review of the facility records were conducted which confirm that the facility does not have a current surety bond to manage resident funding. An interview with 6 residents were conducted, 6 out 6 residents state that they have their own money and the facility does not handle any financial assets. Based on the information gathered, it is unclear if the facility staff failed to safeguard the resident’s money.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2024

LIC9099 (FAS) - (06/04)

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