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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294328
Report Date: 10/29/2021
Date Signed: 10/29/2021 03:56:10 PM

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: 85DATE:
10/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Marife DuewelTIME COMPLETED:
12:57 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Annual Inspection visit today, and met with administrator(ADM) Merife Duewel.

Upon Arrival, LPA called the front desk to open the main entrance door. The facility front desk staff took LPA's body temperature, asked the infection control questionnaires, and checked LPA in the visitor log book.

LPA toured the facility inside out with ADM. LPA observed the COVID posters in facility. LPA observed many hand sanitizers in the facility. LPA toured the dinning noon, common area, activity room. Trash cans were observed with covers. LPA toured the resident rooms in Assistant LIving Unit, and Memory Care Unit. The beds in shared rooms were observed 6 feet apart. The trash cans in resident rooms were observed with covers, but some trash cans in the restrooms of resident rooms were observed without covers. ADM stated the facility will fix this in two weeks. All staff were observed wore masks. All the resident rooms have a closet with hand sanitizers and PPE in front of the bedroom door. Hand sanitizers were observed by all the elevators.

Medication closet in Medication carts were observed locked. Room temperature was at 73 degree F. The check dates of Fire distinguishes were observed within one year. Hot water temperature was at 117 degree F. Smoke detectors were checked and all were working. LPA toured the courtyard, nothing was observed abnormal.

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SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 FONTANA
FACILITY NUMBER: 435294328
VISIT DATE: 10/29/2021
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LPA checked the PPE supplies, PPE supplies were observed sufficient. LPA checked the food supplies. 2 day perishable food supplies and 7 day nonperishable food supplies were observed sufficient.

LPA discussed LIC808 with ADM. ADM stated all the residents and staff are fully vaccinated. ADM stated the residents and staff who had Pfizer vaccines already received the booster shots. ADM stated the residents and staff who had Johnson and Johnson or Moderna vaccines were scheduled for the booster shots. ADM stated the facility already had the N95 fitting test for all staff.

No deficiency or allegation was issued today. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was emailed to ADM.

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SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021
LIC809 (FAS) - (06/04)
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