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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202509
Report Date: 11/09/2024
Date Signed: 11/09/2024 12:49:16 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
08/08/2023 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20230808140941
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: 25DATE:
11/09/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Nicholas InnehTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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9
Facility did not follow a physician’s order for a special diet
Resident was yelled at in the facility
Resident did not feel safe at the facility
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: Facility did not follow a physician’s order for a special diet
It was alleged that the facility staff did not follow a physician’s order for a special diet. Based on interviews conducted it was learned that on 09/01/2023, R1 was sent out to the hospital due to consistent throat pain and was discharged with a blended diet. When R1 came back to the facility and their new diet was implemented, R1 refused to eat what was provided to them.
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)
Page: 1 of 2
Control Number 26-AS-20230808140941
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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The facility attempted to provide R1 other options however all R1 wanted was a small amount of rice and mashed potatoes as the resident’s throat continued to hurt. In addition, the facility conducted a care conference with the R1’s case manager to find the next steps to help support R1. Based on the information gathered, it is unclear if the facility did not follow a physician’s order for a special diet.

Allegation: Resident was yelled at in the facility.

It was alleged that facility residents were yelled at in the facility. During the course of this investigation, LPA conducted resident and staff interviews. Based on 3 staff interviews, it was denied that staff yelled at a resident in the facility. 3 out 3 staff members deny that they have witnessed any other staff members yelling at residents during their shifts. An interview with 5 residents were conducted, 5 out 5 residents state deny that they have been yelled at by staff members or any other residents. 5 out 5 residents deny that they have yelled at or have heard any other residents yell at each other. Based on the information gathered, it is unclear if the resident was yelled at in the facility.

Allegation: Resident did not feel safe at the facility.

It was alleged that the facility residents did not feel safe at the facility. During the course of this investigation, LPA conducted resident and staff interviews. Based on 5 resident interviews. 5 out 5 residents state that they feel safe at the facility. 5 out 5 residents state that staff make them feel safe and do not report any issues at this time. Based on the information gathered, it is unclear if the facility residents do not feel safe at the facility.

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)
Page: 2 of 2