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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200085
Report Date: 01/04/2024
Date Signed: 01/04/2024 03:25:51 PM

Document Has Been Signed on 01/04/2024 03:25 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: 4DATE:
01/04/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Administrator Joseph Anthony OlivaTIME COMPLETED:
03:30 PM
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On January 4, 2024, Licensing Program analysts (LPA's) Manuel Monter, and Steve Chang conducted an unannounced case management visit to check if the facility is complying with their plan of action, after being cited on December 19, 2023. LPA's observed 4 residents in the facility with 2 staff members.

During today's visit, LPA's toured the facility inside and out with ADM. LPA's did not observe S1 working at the facility, the staff member who was excluded on December 19, 2023. LPA's observed the locked storage units the backyard. ADM opened the locked storage units and the storage units are being used as storage units. ADM stated the excluded staff member no longer works at the facility since December 19, 2023 and has not entered the facility since then.

ADM stated the facility's plan of action regarding the covid is to test the residents again in 5 days because only 1 resident tested positive. If a resident tests positive, then we quarantine them. ADM stated he already sent an incident report regarding the covid positive case. ADM stated there is no change in visitors policy, but he encourages them to wear masks. ADM stated he also informed the family's of the coivd positive case in the facility.

No deficiencies cited during today's visit. This report was reviewed with ADM Joseph Anthony Oliva and a copy of the signed report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024
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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