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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294328
Report Date: 01/31/2023
Date Signed: 01/31/2023 05:04:40 PM


Document Has Been Signed on 01/31/2023 05:04 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
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: 75DATE:
01/31/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Marife DuewelTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management incident investigation visit, and met with Administrator (ADM) Marife Duewel.

The purpose of today's visit was to physically inspect the safety of the facility and reviewed the Plan of Action.

LPA inspected the main entrance door and the lock. LPA inspected the trimmed shrubs and bushes to eliminate hiding spot. LPA checked the exterior lighting to be adequate.

LPA discussed with ADM regarding the self-defense service to provide to staff and the grief management and counseling for staff. LPA obtained documents and staff signature log regarding the grief management. The self-defense service is still on going.

Based on the inspection, observation, the interview conducted, and documents reviewed, there were no citation issued today.

Exit interview was conducted with ADM. The report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2023
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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