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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435200957
Report Date: 08/14/2024
Date Signed: 08/14/2024 03:49:23 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/11/2022 and conducted by Evaluator Christine Dolores
COMPLAINT CONTROL NUMBER: 26-AS-20220411150326
FACILITY NAME:VILLA AMORFACILITY NUMBER:
435200957
ADMINISTRATOR:VALIN, A & VFACILITY TYPE:
740
ADDRESS:17605 HILL ROADTELEPHONE:
(408) 782-6767
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY:6CENSUS: 4DATE:
08/14/2024
UNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Virgil ValinTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Night supervision staff did not respond to resident's call for help
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to deliver the finding of the above allegation. LPA met with Administrator, Virgil Valin.

On 04/11/2022, the Department received a complaint alleging the night supervision staff did not respond to resident’s call for help. On 04/19/2022, the initial complaint investigation was conducted.

The following documents were obtained to include four residents physician's report, 4 resident's needs and services plan, LIC624, staff schedule for the month of April, LIC500, and police report records.

PAGE 1 OF 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 26-AS-20220411150326
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 AMOR
FACILITY NUMBER: 435200957
VISIT DATE: 08/14/2024
NARRATIVE
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On 04/06/2022, the Sheriff’s Department was contacted and found a resident (R1) outside at 3:00AM calling for help. R1 is legally blind and the Sheriff’s were trying to get ahold of the live-in staff (S1) for over 45 minutes with no success. The Administrator was contacted after, and the live-in staff came out of the room.

Based on interview with the Administrator (ADM), it was stated that they have 2 live-in staff at the facility. ADM questioned the staff on why they couldn’t hear the Sheriff banging on their door. ADM states the staff were sleeping at the time and was apologetic. ADM states the facility does not have an awake care staff because the residents are independent and does not require night-time supervision. ADM states the live-in staff are only required to do midnight bathroom checks. It was stated that they used to have alarms on the door, but it wasn’t serving any purpose because the residents are high functioning. Residents are free to go outside in the driveway or the backyard.

Based on interview with staff (S1), S1 states to have checked in on the resident’s around 2:00 – 2:30AM and observed R1 was in the room. After 2:30AM, S1 did not know why and when R1 went outside. S1 states to have not heard the knocking because S1 was sleeping.

Based on resident interview, it was stated that R1 went outside to get some fresh air when he/she fell down and couldn’t get up. R1 was calling for help. R1 denied any pain when he/she fell.

The review of records confirms that R1 was sitting outside of the facility yelling for help. The Sheriff’s knocked on S1’s locked door hard and loud for approximately 45 minutes but was unable to wake up S1.

The Department has investigated the above allegation. Based on interview, record review and observation the preponderance of evidence standard has been met, therefore, the above allegation is substantiated. A deficiency was cited per California Code of Regulations, Title 22. See LIC9099-D. A case management visit was conducted on 08/14/2024 due a violation observed during the complaint investigation. See LIC809. This report was reviewed with Administrator, Virgil Valin and a copy of the report and appeal rights were provided. PAGE 2 OF 2.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20220411150326
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 AMOR
FACILITY NUMBER: 435200957
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
08/15/2024
Section Cited
CCR
87415(a)(1)
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(a) The following persons providing night supervision from l0:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, ... and shall be available as indicated below to assist in caring for residents in the event of an emergency. (1) In facilities caring for less than sixteen (16) residents, there shall be a qualified person on call on the premises. This requirement is not met as evidenced by:
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Licensee will submit a written plan regarding the section cited to LPA Dolores via email by POC due date.
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Based on interview, record review and observation the licensee did not ensure the on-call staff on the premises was available to assist in caring for R1 timely when R1 was outside of the facility yelling for help 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.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3