<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202768
Report Date: 03/19/2025
Date Signed: 03/19/2025 01:42:28 PM

Document Has Been Signed on 03/19/2025 01:42 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 TWOFACILITY NUMBER:
435202768
ADMINISTRATOR/
DIRECTOR:		MARQUEZ,MARIA LORENZOFACILITY TYPE:
735
ADDRESS:2403 PEBBLE BEACH DR.TELEPHONE:
(408) 622-8144
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 6CENSUS: 6DATE:
03/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Staff S3, Kara MontecarloTIME VISIT/
INSPECTION COMPLETED:
01:50 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
Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Staff S3, Kara Montecarlo. During the visit, LPA observed 0 residents and 3 staff. LPA explained the purpose of the visit. LPA requested staff to contact facility Administrator. Staff S1 stated the facility administrator is out on leave. Staff S1 provided LPA with the contact information for Patrick BInaro, the Administrator Designee (AD). AD stated he would not be able to visit the facility. AD stated staff S3 would be able to assist LPA and sign on his behalf.

LPA toured the facility inside out with S3 which included the Living room, kitchen, dining room, 3 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. While touring bedroom #2, LPA observed a sliding screen glass door. LPA attempted to open door, but the door was stuck. LPA observed a stick obstructing the path of the sliding screen glass door. (Photograph was taken.)

While touring facility hallway bathroom, LPA observed the shower walls contained soap scum. LPA observed the window attached to the same shower, had a yellowish-dark green substance on the edges of the window. (Photograph was taken.)

While touring the facility kitchen, LPA observed an indentation on the wall next to the dinning room table. (Photograph was taken.)

While touring the facility living room, LPA observed the carpet was worn down, in the area next to the kitchen (Photograph was taken.)

While touring the backyard, LPA observed the concrete was cracking in several areas. . LPA also noted green moss growing on orange bricks in the backyard. (Photographs were taken.) Page 1 Out of 3
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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 TWO
FACILITY NUMBER: 435202768
VISIT DATE: 03/19/2025
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
26
27
28
29
30
31
32
While touring the backyard, LPA also observed the sliding screen door for bedroom #4 was missing. Staff S3 stated resident R2 had removed it yesterday afternoon. S3 stated the handy man usually comes Thursday or Friday to fix issues.

While touring the kitchen, LPA observed the cooktop had grime and burnt up build up. LPA observed the wall next to the cook top had stains. LPA also observed the oven next to the cooktop had stains on surface. (Photograph was taken.)

While touring bedroom #4, LPA observed the hardwood floor, directly entering the bathroom was damaged, causing slight indentations were the boards meet. (Photograph was taken.)

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 to range from 108-110 degrees F in resident bathrooms.

Fire extinguisher was serviced in March 14, 2025. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S3, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on February 17, 2025.

LPA reviewed 3 resident medications and centrally stored medication records. While reviewing resident R3's medications, LPA observed a medication tablet, on the bottom of the clear box containing all the resident medications. S3 stated she believes it was accidentally just popped. S3 stated she tapped the other medication that have a slight opening, and that are at risk of falling out of its container. (Photograph was taken.)

Page 2 Out of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 03/19/2025 01:42 PM - It Cannot Be Edited


Created By: Manuel Monter On 03/19/2025 at 12:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA attempted to open bedroom #2's glass sliding door, but the door was stuck. LPA observed a stick obstructing the path of the sliding screen glass door. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2025
Plan of Correction
1
2
3
4
Staff S3 removed the stick during visit. ADM stated he will send a letter of undertstanding regarding the regualation. ADM stated he will send the plan of correction to LPA by POC date, March 20, 2025.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 03/19/2025 01:42 PM - It Cannot Be Edited


Created By: Manuel Monter On 03/19/2025 at 12:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(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.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. Based on LPA's tour of the facility, LPA noted the following: LPA observed a mouse in the facility kitchen. LPA also observed other physical plant issues noted in 809 & 809-C. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2025
Plan of Correction
1
2
3
4
ADM stated he will send a written plan of action on how to address the physical plan issues noted on report. ADM stated his plan of action will ensure the facility is clean, safe, sanitary and in good repair at all times for the safety and well-being of residents in care.
Type B
Section Cited
CCR
80075(k)(5)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (5) Each client's medication shall be stored in its originally received container.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. While reviewing resident R3's medications, LPA observed a medication tablet, on the bottom of the clear box containing all the resident medications. S3 stated she believes it was accidentally just popped. S3 stated she tapped the other medication that have a slight opening, and that are at risk of falling out of its container. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2025
Plan of Correction
1
2
3
4
ADM stated he will send a letter of understanding regarding the reguation. ADM stated he will send a written plan of action on how he will ensure Each residents medications are stored in its originally received container. ADM stated he will send the written plan of correction by POC date, March 26, 2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
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 TWO
FACILITY NUMBER: 435202768
VISIT DATE: 03/19/2025
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
26
27
28
29
30
31
32
LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident P&I records. LPA conducted interviews with 3 staff. Residents were attending day program during LPA's visit.

While LPA was writing report, LPA observed a mouse enter the kitchen from the staff area, and run towards the area behind the fridge. Staff S3 stated pest control has been coming since February of last year.

Deficiencies cited during today's visit. This report was reviewed with Staff S3, Kara Montecarlo and a copy of the signed report was provided. Appeal Rights were provided. Page 3 Out of 3. END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5