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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294328
Report Date: 05/27/2020
Date Signed: 05/27/2020 11:21:55 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:VILLA FONTANAFACILITY NUMBER:
435294328
ADMINISTRATOR:DUEWEL, MA. FELICITAS V.FACILITY TYPE:
740
ADDRESS:5555 PROSPECT ROADTELEPHONE:
(408) 255-5555
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY:104CENSUS: 92DATE:
05/27/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Marife DuewelTIME COMPLETED:
11:00 AM
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On 5/27/2020, Licensing Program Analyst (LPA) Karen Taku conducted an unannounced Case Management -Tele-visit. Due to COVID19 preventative measures, CCLD has suspended on-site visits. LPA spoke with Administrator Marife Duewel.

The purpose of today’s tele-visit is to obtain additional information, regarding a Death Report received on 5/12/2020 in which a resident (R1) was found with no pulse and pronounced dead by paramedics.

During Tele-visit, LPA requested a copy of R1's Physician's Report, Appraisal/Needs and Services Plan, Functional Capability Assessment, and Death Report.

No deficiencies cited.

This case management will be kept open pending requested documents.

A copy of this report was reviewed and provided to the Administrator via email for signature
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Karen TakuTELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2020
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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