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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202768
Report Date: 08/04/2023
Date Signed: 08/04/2023 04:48:47 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/31/2023 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20230731114728
FACILITY NAME:VILLA GLEN HOME TWOFACILITY NUMBER:
435202768
ADMINISTRATOR:MARQUEZ,MARIA LORENZOFACILITY TYPE:
735
ADDRESS:2403 PEBBLE BEACH DR.TELEPHONE:
(408) 393-8075
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY:6CENSUS: 6DATE:
08/04/2023
UNANNOUNCEDTIME BEGAN:
03:04 PM
MET WITH:Administrator Maria MarquezTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Staff did not properly supervise resident, resulting in resident wandering into neighbors yard
INVESTIGATION FINDINGS:
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Licensing Program Analyst's (LPA's) Manuel Monter and Simi Rai conducted an unannounced complaint investigation regarding the above allegation. LPA's met with Administrator (ADM) Maria Marquez.

LPA's requested staff schedule and facility roster. LPA's also requested resident R1's physicians report, appraisal/needs and services plan, and progress notes.

LPA's interviewed ADM regarding the allegations. ADM admitted that resident R1 had left the facility from the front door unassisted for about 10 minutes and 2 out of 2 staff present at the facility were occupied and did not notice R1 leaving the facility. ADM stated a neighbor had to inform the staff at the facility that the resident had left the facility unattended.

Page 1 out of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023
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 4
Control Number 26-AS-20230731114728
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 TWO
FACILITY NUMBER: 435202768
VISIT DATE: 08/04/2023
NARRATIVE
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Based a review of R1's Appraisal/Needs and services plan, resident R1 requires constant visual supervision. R1 also needs the assistance of a responsible person when he/she access the community. The form states that previously, AWOL had been a large problem for R1.

A review of R1's physicians report states that R1 CANNOT leave the facility unassisted.

A review of R1's Individual program plan states that R1 "has never traveled independently. He/she requires constant visual supervision and the assistance of a responsible person when he access the community. Previously, AWOL had been a large problem. "

Based on interviews and documents review the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D.
This report was reviewed with Administrator Maria Marquez and a copy of the report was provided. Appeal Rights was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 26-AS-20230731114728
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 TWO
FACILITY NUMBER: 435202768
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/11/2023
Section Cited
CCR
80061(b)
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80061 Reporting Requirements (b) Upon the occurrence, during the operation of the facility, of any of the event specified...a report shall be made to the licensing agency within the agency's next working day

This requirement was not met as evidenced by
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ADM stated she will submit a written plan of understanding the regulation and ensuring reports will be made to licensing in a timely manner, by POC date.
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Based on interview with ADM, ADM confirmed that the facility did not make an incident report or call the licensing agency to report the incident. This poses a potential heath, safety and personal rights risk 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: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 26-AS-20230731114728
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 TWO
FACILITY NUMBER: 435202768
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2023
Section Cited
CCR
85078(a)(1)
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85078 Responsibility for Providing Care and Supervision (a)(1) The licensee shall provide those services identified in the client's needs and services plan ... to meet the client's needs. This requirement was not met as evidenced by
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ADM will submit a written plan understanding the regulation and plan of action to ensure the welfare of resident health and safety in the facility by POC date.
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Based on a review of R1's needs and services plan, R1 requires constant supervision. ADM stated R1 had left the facility unsupervised for 10 minutes and 2 out of 2 staff were unaware. This poses an immediate heath, safety and personal rights risk 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: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4