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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200085
Report Date: 12/19/2023
Date Signed: 12/19/2023 05:12:01 PM

Document Has Been Signed on 12/19/2023 05:12 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 ANTONIOFACILITY NUMBER:
435200085
ADMINISTRATOR:JOSEPH ANTHONY OLIVAFACILITY TYPE:
740
ADDRESS:1494 KOCH LANETELEPHONE:
(408) 979-1757
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 6CENSUS: 6DATE:
12/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Joseph Anthony OlivaTIME COMPLETED:
05:30 PM
NARRATIVE
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On December 19, 2023, Licensing Program analysts (LPA's) Manuel Monter, Mita Partoza and Licensing Program Manager (LPM) Romeo Manzano conducted a case management visit/inspection during a complaint investigation. LPA's observed 6 residents in the facility with 3 staff members.

As a result of the complaint investigation, the Department issued an immediate exclusion letter to exclude a staff (S1) who is currently works and resides at the facility. The letter was given to and reviewed to S1 and Administrator/Licensee. This report is reviewed and discussed, and a copy is provided.

During a complaint investigation interview with the staff, LPA's and LPM observed staff S2 and his/her spouse exit from the backyard storage area. S2 and his/her spouse was observed folding blankets and storing them at adjacent storage unit. S2 stated he/she was staying in the storage area with his/her spouse while waiting for S2 to leave work and stays until 2PM when his/her child goes out of school daily (Monday to Friday) since the school year began, sometime in August 2023.

Staff S1 and S3 confirmed that S2's spouse comes to the facility, and waits for S2 to finish his/her night shift. S1 and S3 confirmed S2's spouse other also enters the facility to use the restroom as well. LPA's reviewed Guardian, and S2's spouse is not fingerprinted. S2's spouse went to obtain his/her livescan, and was informed to refrain from being present in the facility.

On October 24, 2023, the facility was cited under code 87202(a) by having staff members use the storage area in the backyard as a rest area/living quarter. LPA also inspected the storage area, which contained electric wires. Based on interviews and LPA's observations, facility staff continue to use the backyard storage space as a rest area. A civil penalty is being assessed for the amount of $1,000 for a repeat violation within the same year.
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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2023
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 12/19/2023 05:12 PM - It Cannot Be Edited


Created By: Manuel Monter On 12/19/2023 at 01:31 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 ANTONIO
FACILITY NUMBER: 435200085

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/20/2023
Section Cited
CCR
87202(a)

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87202(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. ...
This requirement was not met as evidenced by
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ADM stated he will send plan of action on how he/she will ensure the facility is adhering to their fire clearence and ensure the facility storage units are not being used as a sleeping/rest area. This is a repeat citation, issued on 10/24/2023.
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Based on observation & interview, the ADM did not comply with the section cited above. LPA observed S2 leaving the storage unit with his/her spouse. S2 admitted that he/she was resting in the storage area. This poses a potential health, safety or personal rights risk to persons in care.
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Type A
12/20/2023
Section Cited
CCR87355(e)(1)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption ... This requirement is not met as evidenced by:
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ADM will review section 87355 and submit a statement of understanding to LPA by POC due date, December 12, 2023.
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Based on interviews, record review and observation the ADM did not ensure S2's spouse received a fingerprint clearance from the Department pior to S2 residing at the facility, which poses an immediate health, safety, and 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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023


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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: VILLA ANTONIO
FACILITY NUMBER: 435200085
VISIT DATE: 12/19/2023
NARRATIVE
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Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D. A civil penalty is being assessed for the amount of $100 ($100 per day x 5 day = $500) for S1's spouse staying at the facility without fingerprints.

During todays visit, LPA's and LPM explained the exclusion letter to S1. LPA's and LPM observed S1 leave the facility effective immediately.

This report was reviewed with Administrator Joseph Anthony Oliva and a copy of the report was provided. Appeal Rights was provided.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC809 (FAS) - (06/04)
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