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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202768
Report Date: 04/11/2024
Date Signed: 04/11/2024 10:54:19 AM

Document Has Been Signed on 04/11/2024 10:54 AM - 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:
04/11/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Administrator Maria Lorenzo MarquezTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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On April 11, 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 2 residents and 2 staff.

LPA requested a copy of staff training documents regarding; Reporting requirements and personal rights.

No deficiencies are being cited during todays visit. Exit interview conducted with Administrator Maria Lorenzo Marquez and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2024
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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