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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202768
Report Date: 09/30/2023
Date Signed: 09/30/2023 08:34:24 PM

Document Has Been Signed on 09/30/2023 08:34 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:
09/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Staff member Paulo NgriaklTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Staff member Paulo Ngriaki. S1. S1 contacted ADM Marquez and she confirmed that S1 could sign the report on her behalf.

LPA toured the facility inside out with S1 which included; the Living room, kitchen, two restrooms and 3 residents bedrooms. The staff areas of the facility was also inspected. Front yard and backyard were inspected. There was no obstruction to block the walkways.

While touring the outside of the facility, at 12:33pm, LPA observed a can of Kingsford lighter fluid, next to a green Kingsford barbecue lighter. LPA asked S1 what that was doing there. S1 said they sometimes have barbecues. LPA asked picked up the container and confirmed the container did have lighter fluid inside.

While touring the hallway bathroom. LPA observed the bathroom window without a screen. LPA also observed a hole in the hallway bathroom wall. LPA observed the bedroom 4's private bathroom window to have a screen, but contains cobwebs. While touring Bedroom #2, LPA observed a hole in the wall the size of the door knob. While touring bedroom #2, LPA observed the sliding screen unattached.

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 75 degree F, and hot water temperature was measured at 107 degrees F in both resident bathrooms.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2023
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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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: 09/30/2023
NARRATIVE
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Fire extinguisher was serviced in 01/30/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by FM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on 09/15/2023.

LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff (S1) and no residents were interviewed as they were leaving to go to the park as LPA toured the facility.

Deficiencies are cited during today's visit. See LIC809D. This report was reviewed with and was signed by staff member Paulo Ngriaki and a copy of the signed report was provided. Appeal Rights were provided.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/30/2023 08:34 PM - It Cannot Be Edited


Created By: Manuel Monter On 09/30/2023 at 01:41 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: 09/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed lighter fluid next to a lighter in the backyard accessible to residents in care. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2023
Plan of Correction
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4
ADM will send plan of action on how the facility will keep Disinfectants, cleaning solutions, and poisons inaccessible to residents in care. ADM will send to LPA by POC date, 10/01/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 09/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/30/2023 08:34 PM - It Cannot Be Edited


Created By: Manuel Monter On 09/30/2023 at 01:41 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: 09/30/2023

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
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Based on observation, the licensee did not comply with the section cited above. LPA observed a hole in the wall in the facility's hallway bathroom. LPA also observed a hole the size of a door knob in bedroom #2. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2023
Plan of Correction
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ADM stated she will send plan of action on how she plans to keep the facility in good repair at all times for the safety and well being of the residents. ADM will send to LPA by POC date, 10/07/2023.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed the kitchen bathroom without a screen. LPA also observed the sliding screen in bedroom #2 unattached. LPA observed bedroom #4's window screen to have cobwebs. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2023
Plan of Correction
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ADM stated she will send plan of action on how she plans to keep window screens in the facility in good repair and free of insects and other debris. ADM will send to LPA by POC date, 10/07/2023.
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: 09/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2023


LIC809 (FAS) - (06/04)
Page: 4 of 4