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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294328
Report Date: 06/03/2021
Date Signed: 06/04/2021 08:13:29 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: 79DATE:
06/03/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Marife DuewelTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Steve Chang and Licensing Program Manager (LPM) Romeo Manzano conducted an unannounced case management incident investigation, and met with administrator (ADM) Marife Duewel.

The purpose of this visit was to obtain additional information on an incident report received by the Department on 06/02/2021 regarding an alleged abuse towards a resident (R1) .

During today's visit, LPA/LPM interviewed the ADM, 3 staff (S1 to S3), R1'a private companion and resident (R1). R1's physician report, Appraisal/Needs and Service Plan, nurses' notes, meeting minutes with R1's family were obtained.

Based on interviews, on 05/11/21, R1 was noted to have a right knee swelling and later on ruled out by R1's PCP on 05/28/21, R1 sustained a fracture on left leg. Staff and R1's companion stated that were no reported incident happened to R1 on or before 05/11/21. Staff stated that R1 did not have a fall since admission to the facility. R1 is bedridden who is not able to reposition in bed who is dependent on all ADLs (Activities of Daily Living) except needs assistance in feeding. R1 needs assistance with transferring to and from bed/chair. R1 was observed and interviewed but not able to respond questions due to neuro-cognitve disorder. Staff denied allegation of physical elder abuse.

Based on available information gathered during today's investigation, LPA conducted observations, records reviewed, and interviews, the Department found that the above incident is UNSUBSTANTIATED. There is not a preponderance of evidence to prove that the incident of elder abuse or neglect did or did not occur.

No citation was issued today. Exit interview conducted with ADM. Due to technical issue, a copy of this report was electrically emailed to ADM for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021
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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