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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200085
Report Date: 08/15/2024
Date Signed: 08/15/2024 02:13:11 PM

Document Has Been Signed on 08/15/2024 02:13 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/
DIRECTOR:
JOSEPH ANTHONY OLIVAFACILITY TYPE:
740
ADDRESS:1494 KOCH LANETELEPHONE:
(408) 979-1757
CITY:SAN JOSESTATE: CAZIP CODE:
95125
CAPACITY: 6CENSUS: 6DATE:
08/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Administrator Joseph Anthony OlivaTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Manuel Monter and Marcela Yanez conducted an unannounced annual inspection visit, and met with Administrator (ADM) Joseph Oliva. During the visit, LPA observed 3 residents and 3 staff. LPA explained the purpose of the visit.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 3 restrooms and 6 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways.

Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 72 degrees F, and hot water temperature was measured at 108 degrees F in both resident bathrooms.

Fire extinguisher was serviced in 04/29/24. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on 08/06/2024.

LPA conducted interviews with 1 staff and 1 residents. LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. While reviewing resident R2's medications, LPA's observed medication #1's bottle did not contain the prescription label. R2's medication bottle 1 did not have the prescribing physician, dosage, or name of resident. ADM stated the box was discarded.

a Deficiency are being cited during today's visit. This report was reviewed with Administrator Joseph Anthony Oliva and a copy of the signed report was provided. Appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2024
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 08/15/2024 02:13 PM - It Cannot Be Edited


Created By: Manuel Monter On 08/15/2024 at 01:51 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: 08/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(3)
87465 Incidental Medical and Dental Care (h) (3) Each container shall carry all of the information specified in (6)(A) through (E) below plus expiration date and number of refills.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. While reviewing resident R2's medications, LPA's observed medication #1's bottle did not contain the prescription label. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2024
Plan of Correction
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ADM stated he will send a letter of understanding regarding the regulation. ADM stated he will send the plan of correction to LPA by POC date, August 22, 2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024


LIC809 (FAS) - (06/04)
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