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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202768
Report Date: 03/19/2025
Date Signed: 03/19/2025 01:46:56 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
03/10/2025 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20250310151527
FACILITY NAME:VILLA GLEN HOME TWOFACILITY NUMBER:
435202768
ADMINISTRATOR: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
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrative Assistant Kara MontecarloTIME COMPLETED:
01:55 PM
ALLEGATION(S):
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Staff did not supervise resident, resulting in resident wandering unsupervised
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to investigate the above allegations. 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 Administrative Assistant Kara Montecarlo could sign on his behalf.

On March 10, 2025, the Department received a complaint alleging staff did not supervise resident, resulting in resident wandering unsupervised.

Page 1 Out of 4.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 26-AS-20250310151527
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: 03/19/2025
NARRATIVE
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On March 10, 2025, the Department received an incident report for resident R1. The incident report stated the following: “On Saturday, 03/08/25 at approximately 2:40pm, R1, requested to take a nap in his/her bedroom…At 2:48pm, R1 opened the sliding door in his/her bedroom which leads to the back yard (R1 has one door/exit in his/her bedroom that leads to the backyard, while the other door/exit leads to the hallway inside the home). R1 then opened the side gate in the back yard and walked to the driveway in front of the house. At 2:49pm, a staff that was in the kitchen looked through the kitchen window and saw R1 outside and immediately redirected R1 back into the house. R1 went back into his/her bedroom and tucked him/herself back into bed. At 3:02pm, R1 opened the same sliding door in his/her bedroom which exits to the back yard and walked to the front yard via the side gate. At 3:05pm, staff went to his/her bedroom and noticed R1 was not in his/her bed. Staff walked throughout the house and checked all rooms and R1 was not in any of the rooms. They also checked the back yard and R1 was not there. Staff then walked to the front yard and saw R1 on the sidewalk of the next-door neighbor’s home. Staff immediately brought R1 back into the home…There were five staff on shift during the time of this incident…No injuries were sustained during this incident.”

On March 14 & 17, 2025, Licensing Program Analyst Manuel Monter interviewed Witness W1 and W2. Both Witnesses interviewed stated that on March 8, 2025, he/she observed resident R1 walking in the street, unsupervised. W1 stated W2 ran to the care home and informed the staff that R1 was outside the home, unsupervised. Witness W1 stated there was also an incident where resident R2 was observed outside his/her home on December 30, 2024.

On March 19, 2025, Licensing Program Analyst Manuel Monter interviewed staff S1-S3 regarding resident R1's elopement on March 8, 2025. All staff interviewed stated they were working on March 8, 2025. S1 stated R1 had initially made an attempt to elope, but staff redirected him/her. S1 stated the second attempt, R1 did leave the facility. S1 stated he/she noticed that R1's room was quite and noticed R1 was gone. S1 stated staff searched the home. S1 stated as he/she was headed towards the street, a neighbor had told him/her that one of the residents was alone and wandering. S1 stated he/she and S3 brought R1 back to the home.

Staff S2 stated he/she was supervising the residents when Staff S1 told him/her that R1 wasn't found in the home. S2 stated R1 was found outside the home by S1. Page 2 Out of 4.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 26-AS-20250310151527
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: 03/19/2025
NARRATIVE
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Staff S3 stated on March 8, 2025 R1 had made an initial attempt to elope, but was redirected. S3 stated R1 managed to elope from the facility on his/her second attempt, by going thru the side gate. S3 stated R1 was found on the sidewalk, in front of the home, passing back and forth. S3 stated R1 was redirected by S1 and him/herself. S3 stated he/she did not observe any neighbor when R1 was brought back to the home.

On March 19, 2025, Licensing Program Analyst Manuel Monter interviewed staff S1-S3 regarding resident R2's elopement December 30, 2024. Staff S1 stated he/she doesn't remember what happened on December 30, 2024. Staff S2 stated R2 did leave the facility unsupervised on December 30, 2024. S2 stated he/she was using the restroom, when R2 managed to leave the facility. S2 stated R2 was found near a neighbors home. S2 stated that day, police officers came and spoke to S2, to ensure he/she was supervising R2. Staff S3 stated he/she was unaware of this elopement. S3 stated an incident report was not sent. S3 confirmed that resident R2 had a 1 on 1 staff back in December 2024.

Based on a review of R1’s Individual Program Plan (IPP), is dated October 19, 2023. The IPP states, under Safety Skills/Disaster preparedness: “R1 would need full assistance if a natural disaster occurred. R1 does not know how to alert those around him/her or get to safety him/herself. The IPP states, under Behaviors: “R1 has a history of engaging in SIB (Self injurious behaviors). R1 would kick him/herself in the shin to hurt him/herself when he/she became frustrated. This behavior occurred at least 3-4 times a month, both at the home and at day program. R1 also likes long hair and has the tendency to grab someone’s hair unexpectedly. R1 has a history of physical aggression and has acted towards peers at least several times in the last 12 months, without warning. R1 requires assistance from day program and home staff for redirection.”

Based on a review of R1’s Physicians Report, dated August 16, 2024, R1 cannot leave the facility unassisted.

Based on a review of evidence provided, resident R2, on December 30, 2024, at 1:03pm, R2 was observed walking towards a neighbors front door. R2 was observed lingering by the front door, unsupervised. R2 left the front of the neighbors home at 1:06pm.



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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
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20250310151527
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: 03/19/2025
NARRATIVE
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Based on a review of R2’s Individual Program Plan (IPP), dated June 27, 2023, R2 " requires constant visual supervision and the assistance of a responsible person when he/she accesses the community." )

Based on a review of R2’s physicians report, dated December 9, 2023, R2 cannot leave the facility unassisted.

Based on record review, the Department did not receive an incident report for R2 lingering outside the home unsupervised.

An immediate civil penalty of $500.00 is being assessed against the facility today for violation the absence of supervision, which resulted in R1 and R2 wandering from the facility unsupervised.

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 Administrative Assistant Kara Montecarlo and a copy of the report was provided. Appeal Rights was provided.

Page 4 Out of 4. 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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20250310151527
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: 03/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/20/2025
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement was not met as evidenced by;
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ADM stated she will write a detailed plan of action on how she will ensure residents are receiving care and supervision to meet their needs and to prevent elopements.
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Based on investigation conducted, R1 eloped from the facility on 3/8/25. R2 was outside the home unsupervised on 12/30/25. R1’s &R2’s physicians report state R1 & R2 cannot leave the facility unassisted. This poses/posed an immediate health, safety or personal rights risk to persons in care.
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Type B
03/19/2025
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 AD, AD confirmed that the facility did not make an incident report or call the licensing agency to report R2 being outside the facility on 12/30/24, unsupervised. 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: 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
LIC9099 (FAS) - (06/04)
Page: 5 of 5