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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 01:34:40 PM

Substantiated


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
01/17/2024 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20240117134530
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:
01:00 PM
MET WITH:Nicholas Inneh TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility has bed bugs
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 has bed bugs
It was alleged that the facility has bed bugs. During the course of this investigation, LPA conducted interviews and reviewed facility documentation. Based on interviews conducted it was learned that the facility was notified that there may be bed bugs in a residents room. The facility obtained pest control services as soon as they were notified and provided treatment. It was learned that the bed bugs were secluded in the residents room and did not spread into other parts of the facility. Based on the information gathered, the facility had bed bugs.
The Department has investigated the above allegation and the preponderance of evidence standard has been met, therefore, the above allegation is substantiated.

A deficiency is being cited per California Code of Regulations, Title 22. See LIC9099-D. This report was reviewed with Administrator, Nicholas Inneh and a copy of the report and appeal rights were provided.
Substantiated
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 5
Control Number 26-AS-20240117134530
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2024
Section Cited
CCR
80087(a)(1)
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80087(a)(1)
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

(1) The licensee shall take measures to keep the facility free of flies and other insects.
This is not met as evidenced by:
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Licensee has obtained pest control services. POC has been cleared as of this date.
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The licensee did not ensure that the facility was free of pests such as bed bugs. It was learned that upon admission the resident room obtained bed bugs and was treated upon notice.
This poses a potential health, safety and personal rights risks 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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
01/17/2024 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20240117134530

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:
01:00 PM
MET WITH:Nicholas Inneh TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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9
Facility is not adhering to SSI/SSP Basic Service Rate
Facility does not keep grounds free of litter
Facility does not have sufficient staff to provide care to the residents
Facility does not provide the residents with basic services to include hygiene items
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 24. A brief interview with FDA Inneh was conducted.
Allegation: Facility is not adhering to SSI/SSP Basic Service Rate
It was alleged that the facility is not adhering to SSI/SSP Basic Service Rate. During the course of this investigation, LPA conducted interviews and reviewed facility documentation. Based on interviews conducted, it was learned that the resident recently had a change of charges for their board and care rate based on the new SSI/SSP Basic Service Rate for 2024 with an additional rate for additional services, however it was learned that due to a misunderstanding in service rates communicated with R1 and their family, the facility no longer charged the additional rate for additional
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: 3 of 5
Control Number 26-AS-20240117134530
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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services. A review of R1’s records confirm that while the facility did charge the correct SSI/SSP Basic Service Rate, they did not charge R1 with the additional service rate of $13.98. Based on the information gathered, it is unclear if the facility is not adhering to SSI/SSP Basic Service Rate.

Allegation: Facility does not keep grounds free of litter

It was alleged that the facility does not keep grounds free of litter. During the course of this investigation, LPA conducted interviews and toured the facility. Based on interviews conducted, it was learned that the facility does have staff conduct housekeeping duties including but not limited to cleaning resident rooms, bathrooms, kitchen, mopping, disinfecting, and cleaning the outside surroundings. In addition, the facility conducts 2 hour rounds outside to ensure that facility grounds are free of any litter. LPA toured the facility on 10/12/2024 which included but were not limited to the kitchen, resident rooms, bathrooms, and outside grounds. During the course of this visit LPA did not find any indication that the facility does not keep grounds free of litter. The outside area also had a designated area for smoking purposes in which cigarette buds were ensured to be disposed of in the designated area. Based on the information gathered it is unclear if the facility does not keep grounds free of litter.

Allegation: Facility does not have sufficient staff to provide care to the residents

It was alleged that the facility does not have sufficient staff to provide care to the residents. During the course of this investigation, LPA conducted interviews and reviewed facility documentation. Based on interviews conducted with 3 staff. 3 out 3 staff state that they believe that they have sufficient staff to provide care to the residents. An interview with 5 residents was conducted. 5 out 5 residents deny not being able to obtain help from staff. 5 out 5 residents state that they do not have any issues with the care that they obtain from the staff. In addition, LPA reviewed facility records that show that they have at minimum 3 staff members and a medication technician on site to provide care and supervision on site at all times. Based on the information gathered it is unclear if the facility does not have sufficient staff to provide care to the residents.

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: 5 of 5
Control Number 26-AS-20240117134530
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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Allegation: Facility does not provide the residents with basic services to include hygiene items

It was alleged that the facility does not provide the residents with hygiene items. During the course of this investigation, LPA conducted interviews and reviewed facility documentation. Based on interviews conducted, staff denied that they do not provide residents with hygiene items. It was found that hygiene items were stored at the facility which included but were not limited to, body soap, shampoo, conditioner, toothbrushes, and toothpaste. Many times family members will provide the facility with additional supplies such as electric shavers to help assist with their loved ones at the facility. An interview with 5 residents was conducted. 5 out 5 residents deny that they have to provide their own hygiene items. 5 out 5 residents state that the facility provides everything for them. In addition, LPA reviewed facility storage and found that the facility houses hygiene supplies. Based on the information gathered it is unclear if the facility does not provide the residents with hygiene items.

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: 4 of 5