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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294328
Report Date: 01/06/2026
Date Signed: 01/07/2026 08:57:42 AM

Document Has Been Signed on 01/07/2026 08:57 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 FONTANAFACILITY NUMBER:
435294328
ADMINISTRATOR/
DIRECTOR:		DUEWEL, MA. FELICITAS V.FACILITY TYPE:
740
ADDRESS:5555 PROSPECT ROADTELEPHONE:
(408) 255-5555
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY: 104CENSUS: 88DATE:
01/06/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:07 AM
MET WITH:Marife DuewelTIME VISIT/
INSPECTION COMPLETED:
11:38 AM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management - incident visit and met with Executive Director (ED) Marife Duewel.

On 01/02/2025, the Department received a notice that resident R1 had a fall and was sent to hospital on 12/31/2025 and R1 had a fall on 12/202025.

The Department interviewed R1's family member (FM). FM stated that he/she does not find the facility staff had fault for the incident on 12/31/2025 and stated the facility provides good care to R1. FM confirmed R1 had a fall on 12/20/2025.

LPA requested R1's physician report and appraisal needs and service plan.

LPA interviewed ED. ED stated on 12/20/2025,around 6:30AM after R1's morning care, R1 had a fall at memory care unit hallway. ED stated staff found R1 was on the floor and called 911 immediately. R1 was sent to hospital.

ED stated on 12/31/2025, around 12:30AM, staff saw R1 was walking at the memory care unit hallway. Staff S1 saw R1 was falling and tried to help but was unable to stop R1's falling. S1 called Med Tech (S2). S2 came on site and assessed R1 and called 911 immediately. R1 was sent to hospital. ED stated R1 still at hospital today.

Continue on LIC809-C. Oage 1 of 2.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Chihhsien Chang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 FONTANA
FACILITY NUMBER: 435294328
VISIT DATE: 01/06/2026
NARRATIVE
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LPA interviewed Wellness Director (WD). WD stated resident R1 had fall on 12/20/2025 and 12/31/2025. WD stated staff found R1 was on the floor on 12/20/2025 and 12/31/2025 and called 911 immediately.

The facility did not send incident report for R1's fall and was sent to hospital on 12/20/2025 to CCL office.

Based on the review of R1's appraisal/needs and service plan, the facility did not update R1's care plan after R1's fall on 12/2025.

Deficiencies were noted for today's visit, please see LIC809-D.

Exit interview was conducted with ED. The report was provided to ED for reveiw. A copy of the report was provided to ED.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Chihhsien Chang
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/07/2026 08:57 AM - It Cannot Be Edited


Created By: Chihhsien Chang On 01/06/2026 at 10:48 AM
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 FONTANA
FACILITY NUMBER: 435294328

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/13/2026
Section Cited
CCR
87211(a)(1)(D)

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87211 Reporting Requirements(a)(1)(D)Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
This requirement is not met as evidenced by:
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Executive Director stated to submit a plan of correction by the POC due date to ensure to send incident report to CCL office within 7 days of the incidents.
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Based on interview and record review, The facility did not send incident report of R1's fall and was sent to hospital on 12/202025 which poses/posed an potential Health, Safety, or Personal Rights risk to persons in care.
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Type B
01/13/2026
Section Cited
CCR87463(a)

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87463 Reappraisals (a)...The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to...

This requirement is not met as evidenced by:
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Executive Director stated to submit a plan of action understanding regulation by POC due date ensure residents' care plan was updated as needed.
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Based on record review, R1 did not have a reappraisal after the fall on 12/20/2025 and appraisal needs service plan was not updated after R1's incident on 12/20/2025 which poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Chihhsien Chang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2026


LIC809 (FAS) - (06/04)
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