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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202509
Report Date: 12/14/2023
Date Signed: 12/14/2023 10:50:47 AM


Document Has Been Signed on 12/14/2023 10:50 AM - 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: 25DATE:
12/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:NICHOLAS INNEHTIME COMPLETED:
10:55 AM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - other visit. LPA met with Administrator, Nicolas Inneh.

During visit, LPA interviewed 1 staff member regarding a death report the Department received for resident (R1).

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Nicolas Inneh and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
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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