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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202768
Report Date: 04/10/2024
Date Signed: 04/10/2024 01:00:18 PM

Document Has Been Signed on 04/10/2024 01:00 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:
04/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Administrator Maria Lorenzo MarquezTIME VISIT/
INSPECTION COMPLETED:
01:05 PM
NARRATIVE
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On April 10, 2024, Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management-Incident visit regarding an incident report on April 10, 2024 . LPA met with Administrator Maria Lorenzo Marquez and explained the purpose of the visit.

On April 10, 2024, the Department received an incident report stating on April 9, 2024, the ADM was notified by staff that another staff member had allegedly abused a resident.

LPA interviewed 1 staff and requested a copy of S1's files. LPA requested copies of R1 and R2's physicians report, face sheet, and needs and services plan. (Due to facility printer ink being low, LPA requested ADM email the documents to LPA.)

While reviewing the facility personnel Report summary (LIS536), LPA observed staff S1 was not associated to the facility. LPA searched S1's name on Guardian, and observed S1 was not associated to the facility. ADM confirmed and stated S1 was not associated to the facility.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500) for S1 working in the facility without association.

A deficiency is being cited during todays visit. Exit interview conducted with Administrator Maria Lorenzo Marquez and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2024
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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Document Has Been Signed on 04/10/2024 01:00 PM - It Cannot Be Edited


Created By: Manuel Monter On 04/10/2024 at 12:21 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: 04/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2024
Section Cited
CCR
80019(e)(3)

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80019 Criminal Record Clearance(e)All individuals subject to a criminal record review ... shall prior to working, residing or volunteering in ...a licensed facility: (3) Request a transfer of a criminal record clearance... This Requirement was not met as evidenced by
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Licensee will ensure all new and current staff are fingerprint cleared and associated to the facility. Licensee will submit a plan in writing to ensure all new staff are associated to the facility prior to starting work.
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Based on record review, interview, and observation the Licensee did not comply with the section cited above by not requesting a transfer to associate S1 to the facility prior to S1 starting work, which poses a potential health, safety, and personal rights risk to persons in care.
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 Licensee will also submit a plan in writing to audit their facility roster to ensure all current staff are fingerprint cleared and associated to the facility. Licensee will review section 87355 and send a statement of understand of the section and send the facility’s plan to LPA by POC due date via email.

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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.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024


LIC809 (FAS) - (06/04)
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