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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202768
Report Date: 09/21/2023
Date Signed: 09/21/2023 12:21:31 PM

Document Has Been Signed on 09/21/2023 12:21 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:MARQUEZ,MARIA LORENZOFACILITY TYPE:
735
ADDRESS:2403 PEBBLE BEACH DR.TELEPHONE:
(408) 622-8144
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 6CENSUS: 6DATE:
09/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Administrator MarquezTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced case management visit. LPA met with administrator (ADM) Maria Marquez.

On 09/21/2023, Desk Duty officer, LPA Manuel Monter received an incident report form the facility, Villa Glen Home 2. The incident report stated resident R1 was fixated on hurting resident R2 on 9/18/2023. R1 attempted to hit R2 at 10:30pm. Staff intervened and redirected. R1 made another attempt at 12:15am, but was re-directed again. Then before 2am, R1 had entered R2's room and began hitting R2. Staff intervened and 911 was contacted.
On 09/21/2023, at 10:40 am. LPA Monter arrived at the facility and asked ADM questions regarding the incident. ADM stated that she does not know exactly what caused this to occur. ADM stated R1 has not had a change in medication. ADM stated both of the residents have been living at the facility for 3 years. LPA observed R1's bedroom and R2's bedroom are not connected by a wall and are directly across from each other in the hallway. ADM stated there is an awake night shift staff. 3 live in staff at the time.

LPA requested the following documents for R1 & R2;
needs and services, IPP, Physicians Report, progress notes for that week in question. The facility's plan of action to keep the residents safe.

Needs further investigation. No deficiencies cited as this time.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2023
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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