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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202768
Report Date: 04/17/2025
Date Signed: 04/17/2025 04:42:16 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
04/15/2025 and conducted by Evaluator Manuel Monter
COMPLAINT CONTROL NUMBER: 26-AS-20250415083331
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:
04/17/2025
UNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Lead Staff Kara MonteclaroTIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not supervise resident, resulting in resident wandering
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to investigate the above allegations. Staff S1 stated the facility administrator is unable to arrive due to appointment. Staff S1 provided LPA with the contact information for Patrick BInaro, the Administrator Designee (AD). LPA called AD, at 4:20pm. No answer.

On April 15, 2025, the Department received a complaint alleging staff did not supervise resident, resulting in resident wandering unsupervised.

Page 1 Out of 3.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
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 4
Control Number 26-AS-20250415083331
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: 04/17/2025
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
On April 15, 2025, the Department received evidence regarding resident R1. The evidence is time stamped, April 10, 2025, 5:51pm. Based on a review of evidenced provided, resident R1 was lingering near the edge of the facility and neighbors property. R1 then walks on the side walk and begins to approach a neighbors property. A neighbor stated to R1, to "Go home." Note, the evidence shows R1 did not have a staff member supervising him/her, while he/she was walking towards the neighbors home.

On April 15, 2025, LPA interviewed witness W1. W1 stated on April 10, 2025 he/she encountered R1 roaming outside unattended. W1 stated once he/she observed R1 was unsupervised, he/she went to alert the facility staff that R1 was outside near a neighbors home, unsupervised.

On April 17, 2025, LPA Manuel Monter interviewed Staff S1-S3. Staff S1 stated that day R1 was in the front of the home while being supervised by staff S4 and staff S2. Staff S1 stated he/she had finished his/her shift at Villa Glen home 2. Staff S1 stated as he/she was leaving, Staff S4 went back inside. Staff S1 stated staff S2 was cleaning the upper section of the garage, area, from the outside. Staff S1 confirmed the area that S1 was cleaning was directly in front of the garage door, with the garage door closed. Staff S1 stated he/she went to his/her car, which was 2-3 house down the street, car pointed away from the home.

Staff S2 stated that on April 10, 2025, he/she was cleaning the front door area of the home. S2 stated he/she was keeping an eye of R1 while he/she was cleaning. Staff S2 stated a neighbor came and told him/her that R1 was walking by himself/herself. S2 stated he/she called staff S3 and both went to get R1. S2 stated R1 was picked up on the side walk, near the drive way of the neighbors home, on the sidewalk.

Staff S3 stated he/she was in the staff bedroom adjacent to the kitchen. Staff S3 stated there was staff in the front of the home, staff S1 and S2. S3 stated S1 was in his/her taking phone calls in her car, which was parked in the street. S3 stated staff S2 was in the front of the home near the front door. S3 stated she heard staff S2 request for help and they went to pick up R1, who was near the drive way of the neighbors home, on the sidewalk.

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

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 26-AS-20250415083331
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: 04/17/2025
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
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 interviews conducted and empirical observation, there was no line of sight for resident R1, who has eloped in the past. R1 had wandered away from staff's line of sight, resulting in R1 wandering towards a neighbors property, without staff maintaining supervision.

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

A civil penalty of $250 is being cited for a repeat violation, for the following code section: 80078 Responsibility for Providing Care and Supervision (a), which was cited during a complaint investigation visit on March 19, 2025.

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 3 Out of 3. END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 26-AS-20250415083331
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: 04/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/18/2025
Section Cited
CCR
80078(a)
1
2
3
4
5
6
7
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;
1
2
3
4
5
6
7
ADM stated he will submit a written plan of action on how he will ensure staff maintain line of sight for residents who cannot leave the facility unassisted.
8
9
10
11
12
13
14
Based on investigation conducted, R1 wandered away from the facility on 4/10/25. Staff did not maintain line of sight, for R1, who has eloped in the past. R1’s physicians report states R1 cannot leave the facility unassisted. This poses/posed an immediate health, safety or
8
9
10
11
12
13
14
ADM stated he will submit the written plan of action to LPA by POC date, April 18, 2025.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 04/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4