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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200085
Report Date: 10/07/2021
Date Signed: 10/13/2021 09:17:06 AM

Document Has Been Signed on 10/13/2021 09:17 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:VILLA ANTONIOFACILITY NUMBER:
435200085
ADMINISTRATOR:JOSEPH ANTHONY OLIVAFACILITY TYPE:
740
ADDRESS:1494 KOCH LANETELEPHONE:
(408) 979-1757
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 6CENSUS: 5DATE:
10/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Joseph OlivaTIME COMPLETED:
01:30 PM
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Licensing Program Analyst, Steve Nguyen, conducted an unannounced annual inspection with Administrator (AD), Joseph Oliva.

LPA toured facility inside and out. LPA observed: Covid signs are present and in conspicuous vantage points, are exits are free of obstructions, emergency contact for residents were up to date, facility screening protocols will be enforce and staff will be retrained by AD, hand sanitizing station were available throughout facility, medicine cabinet were observed to be locked, paper towers are in use, all rooms in facility are single occupancy and physical distancing was observed to be in practice.

No citation was issued at this time.

LPA went over report findings with Administrator, Joseph, for review and a copy was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Steve Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2021
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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