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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412272
Report Date: 06/27/2019
Date Signed: 06/27/2019 01:23:26 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:JIANG, BILI & HAN, GUANGXUEFACILITY NUMBER:
434412272
ADMINISTRATOR:BILI & GUANGXUEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 207-7413
CITY:SAN JOSESTATE: CAZIP CODE:
95131
CAPACITY:14CENSUS: 10DATE:
06/27/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Guangxue HanTIME COMPLETED:
01:40 PM
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LPA returned to the facility for a case management visit to deliver the inspection report to licensee due to LPA ran into a FAS inconsistent error and was not able to complete the inspection earlier a this morning. LPA met with licensee, Guangxue Han, and explained to him on the nature of this visit.

No Deficiency was cited. Exit interview conducted with Licensee. A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Yangcheng HuangTELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2019
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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