435202766-5-23-2025-26-AS-MMOR-DGXVEC-20250523162208

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202766
Report Date: 05/23/2025
Date Signed: 05/23/2025 04:22:22 PM

Document Has Been Signed on 05/23/2025 04:22 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 ONE		FACILITY NUMBER:	435202766
ADMINISTRATOR/ DIRECTOR:	BINARAO, PATRICK		FACILITY TYPE:	735
ADDRESS:	1727 CURTNER AVE.		TELEPHONE:	(408) 622-8530
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95125
CAPACITY: 6		CENSUS: 6	DATE:	05/23/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Administrator Patrick Binarao		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On, May 23, 2025, Licensing Program Analyst Manuel Monter conducted an unannounced Case Management – incident, in response to a self reported SOC341 regarding alleged physical abuse. On May 15, 2025, the Department received a SOC341 regarding alleged physical abuse. The SOC341 stated the following information: R1 had alleged that staff S1 had struck him/her on approximately March 11, 2025. R1 stated he/she tried turning over resident R2 to his/her side thinking that it would be more comfortable for him/her to sleep. R1 stated that's when a staff (S1) walked in the room to intervene. R1 stated S1 hit him/her on the side of his/her head. Administrator, Patrick Binarao, and Kara interviewed R1 who said that S1 hit him on the side of his/her head because he/she was trying to wake up R2 while he/she was sleeping. R1 said this was the first time he/she has ever been hit by S1. On Wednesday, May 14, Patrick and Kara interviewed staff S1 about the incident. S1 said that R1 entered R2s room to wake R1 up. R1 then tried to put his/her arms around R2 (in a hugging position) and S1 told R1 to stop bothering R2 since he/she was sleeping. R1 did not listen and continued to put his arms around R2. S1 went in the middle of the two individuals. R1 flailed his/her arms, screamed, and ran out of the room into the kitchen where another staff was able to calm him/her down and redirect him/her back into his/her bedroom. When asked if he/she ever hit R1 during the incident, S1 said, "no," and that he/she only put his/her arms in between the two individuals to separate them. On Wednesday, May 14, Patrick and Kara interviewed staff S2 who was on shift during the incident. S2 said that he/she was in the kitchen at the time of the incident. S2 stated he/she did not witnessed S1 hit R1, he/she said, "no,' and did not notice any injuries on R1. Page 1 Out of 2.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 05/23/2025

NARRATIVE

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On May 23, 2025, LPA Monter interviewed ADM. ADM stated the staff do regular checks when residents come back from day program or school. ADM stated facility staff did not observe any marks or bruising on R1, during his/her time at the home, including March 11, 2025. ADM stated nothing was out of the ordinary the first two weeks of March 2025. ADM stated R1 has been on base line. ADM stated he asked R1 to explain or re-enact how S1 stuck him/her. ADM stated R1 only told him that S1 hit him/her on the back of the head.

LPA interviewed R1's Family member (FM). FM stated he/she only knows what has been told to him/her by R1. FM stated, R1 told her, that he/she was trying to reposition R2 on his side, and staff S1 hit R1 on the back of the head with a fist. LPA asked FM if R1 had told him/her the details of the hit, in terms of the force. FM stated he/she was only told that S1 hit R1, on the back of the head with a fist. LPA asked if FM remembers seeing any marks or bruising on R1 in the first two weeks of March 2025. FM stated he/she didn't see any marks or bruising on R1 in the first 2 weeks of March 2025.

LPA interviewed staff S3-S5. All staff interviewed stated they have not staff hit residents. All staff interviewed stated they have not seen staff hit resident R1. All staff interviewed stated in the past 3 months, they have not seen R1 with bruising, bleeding or marks on his/her body.

LPA interviewed residents R1-R6. Resident R1 stated he/she was moving R2 in another position when he/she was sleeping. R1 stated he/she was struck on the left side of the head with an open hand by staff S1. R1 stated he/she hasn't been struck by S1 since that event. Resident R3 stated he/she has not seen staff hitting residents. LPA interviewed Resident R2,R4, R5 and R6. R2,R4, R5, R6 did not respond to LPA's questions, and had behaviors such as not talking, ignoring questions, and being distracted/engaging in other actions during interview.

Based on investigation, records reviewed, and interviews conducted, the Department found that the allegation of alleged physical abuse are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.

No deficiencies cited during today's visit. This report was reviewed with Administrator Patrick Binarao and a copy of the signed report was provided. Page 2 Out of 2. END OF REPORT.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025

LIC809 (FAS) - (06/04)

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