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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430708736
Report Date: 02/13/2024
Date Signed: 02/13/2024 05:47:08 PM

Document Has Been Signed on 02/13/2024 05:47 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:
02/13/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Licensee, Dominica Olivia.TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Simi Rai conducted an case management visit to address information obtained during the complaint investigation 8/15/2023. LPA Rai met with Licensee, Dominica Olivia and stated the purpose of the visit.

During investigation, it was disclosed that the caregivers were providing wound care to resident (R1) and the caregivers are not licensed providers.

During today's visit, LPA interviewed Licensee regarding the issues disclosed during investigation. Licensee stated caregivers who are not licensed providers did change R1's wound care when Home Health nurse were not available and did not see R1 at the facility.

Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. This report was reviewed with Licensee Dominica Olivia. A copy of the report and Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2024
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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Document Has Been Signed on 02/13/2024 05:47 PM - It Cannot Be Edited


Created By: Simranjit Rai On 02/13/2024 at 04:52 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: 02/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/14/2024
Section Cited
CCR
87631(a)(3)(A)

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87631 Healing Wounds (a)(3)(A) The resident shall receive care for the pressure injury from a physician or an appropriately skilled professional.

This requirement is not met as evidenced by:
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Licensee stated to submit a written plan of action and initiate in-service training with the staff by POC due date. Licensee agreed and understood.
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Based on interview, resident (R1) received care for the pressure injury by a non-skilled professional and the wound care was provided by the caregiver which poses/posed an immediate 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.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Simranjit Rai
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024


LIC809 (FAS) - (06/04)
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