<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708736
Report Date: 03/09/2023
Date Signed: 03/09/2023 03:33:57 PM

Document Has Been Signed on 03/09/2023 03:33 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:VILLA VERDEFACILITY NUMBER:
430708736
ADMINISTRATOR:JULIETA EXTRAFACILITY TYPE:
740
ADDRESS:4751 CALLE DE TOSCATELEPHONE:
(408) 978-7937
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY: 6CENSUS: 5DATE:
03/09/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Dominica OlivaTIME COMPLETED:
03:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Christine Dolores and Tracy Pham arrived unannounced to open an initial complaint investigation. During visit, a case management - deficiencies visit was conducted due to violations that were observed. LPAs met with Licensee, Dominica Oliva.

During visit, LPA toured the facility with staff (S1) to include the living room, resident rooms, bathroom, staff living quarters, kitchen, and backyard.

At 11:24am, LPAs observed a large ziplock full of staff medication inside a resident's bedroom. Staff immediately secured the medications.

At 11:34am, LPAs observed 2 bottles of over-the-counter medication / vitamins on the bookshelf and a ziplock full of medications sitting the living room couch. Based on interview, the medications observed were staff's medication. Medications were secured immediately. LPAs observed a resident present in the living room area. Based on record review, the facility has residents with dementia.

A deficiency is being cited per California Code of Regulations, Title 22. See LIC809D.

This report was reviewed with Licensee, Dominica Oliva and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2023
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 2
Document Has Been Signed on 03/09/2023 03:33 PM - It Cannot Be Edited


Created By: Christine Dolores On 03/09/2023 at 03:00 PM
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 VERDE
FACILITY NUMBER: 430708736

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/10/2023
Section Cited
CCR
87705(f)(2)

1
2
3
4
5
6
7
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee immediately secured the medications. Licensee will send a statement of understanding and staff training record to LPA Dolores by POC due date.
8
9
10
11
12
13
14
Based on observation, interview, and record review the facility did not ensure to secure medications which was left accessible to residents with dementia which poses an immediate health, safety, and personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2