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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202766
Report Date: 10/19/2023
Date Signed: 10/19/2023 04:46:52 PM

Document Has Been Signed on 10/19/2023 04:46 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:VILLA GLEN HOME ONEFACILITY NUMBER:
435202766
ADMINISTRATOR:MARQUEZ,MARIA LORENZOFACILITY TYPE:
735
ADDRESS:1727 CURTNER AVE.TELEPHONE:
(408) 622-8530
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 6CENSUS: 5DATE:
10/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Administrator Maria MarquezTIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Maria Marquez. LPA observed 5 staff members on duty, including ADM.

LPA toured the facility inside out with ADM which included; the Living room, kitchen, dinning room, four restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. Front yard and backyard were inspected. There was no obstruction to block the walkways.

Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication cabinet, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 77 degree F, and hot water temperature was measured to range from 106-109 degrees F in resident bathrooms.

Fire extinguisher was serviced in April 14 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on September 10, 2023.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 3 staff (S1 to S2) and 3 residents (R1-R3).

No deficiencies cited during today's visit. This report was reviewed with ADM Maria Marquez and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
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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