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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202766
Report Date: 04/11/2024
Date Signed: 04/11/2024 01:22:18 PM

Document Has Been Signed on 04/11/2024 01:22 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/
DIRECTOR:
MARQUEZ,MARIA LORENZOFACILITY TYPE:
735
ADDRESS:1727 CURTNER AVE.TELEPHONE:
(408) 622-8530
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 6CENSUS: 5DATE:
04/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Administrator Maria Lorenzo MarquezTIME VISIT/
INSPECTION COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, & met with Administrator (ADM) Maria Lorenzo Marquez. During the visit, LPA observed 1 residents and 2 staff.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 4 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways.

While touring resident bedroom #2, LPA observed the window was blocked with a piece of cardboard and a sliding screen door. (Photographs were taken.) ADM stated, the resident has an ongoing behavior and had pushed the flexi glass. ADM stated the facility has a quote and a contractor they are going to use to address this issue. (ADM provided a copy of the estimate) ADM stated the facility is only waiting for parts. While touring the living room, ADM tried to open the sliding screen door. LPA observed the sliding screen door gets stuck, when staff tried to open the screen door. ADM stated the contractor would also address the issue of the sliding screen door getting stuck.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 112 degrees F in resident bathrooms.

Fire extinguisher was serviced in December 27, 2024. 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 March 5, 2024.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
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 ONE
FACILITY NUMBER: 435202766
VISIT DATE: 04/11/2024
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LPA reviewed facility records for 3 staff & 3 residents. LPA reviewed 3 resident medications & centrally stored medication records. LPA reviewed 3 P&I records. LPA conducted interviews with 1 staff and 1 resident. The other residents were attending day program during LPA's visit.

No deficiencies cited during today's visit. A technical violation was given. This report was reviewed with Administrator Maria Lorenzo Marquez and a copy of the signed report was provided.

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END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC809 (FAS) - (06/04)
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