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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294328
Report Date: 04/07/2023
Date Signed: 04/07/2023 04:25:47 PM


Document Has Been Signed on 04/07/2023 04:25 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: 77DATE:
04/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:03 AM
MET WITH:Marrife DuewelTIME COMPLETED:
02:39 PM
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Licensing Program Analysts (LPAs) Steve Chang and Trang Pham conducted an unannounced case management visit and met with Administrator (ADM) Marrife Duewel.

LPAs address the purpose of today's visit to ADM. The Department received an Incident Report on 3/29/2023 for an incident which the facility reported that an inappropriate body contact between a client and a staff occurred at the facility.

LPAs interviewed ADM, 1 staff. LPAs toured some resident bedrooms.

LPAs obtained resident physician report and Appraisal Needs and Service Plan

ADM stated the facility will submit an action plan to prevent the similar incident to happen.

Exit interview was conducted with ADM, The report was provided to ADM for signature. A copy of the report was provide to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2023
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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