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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434416673
Report Date: 12/16/2021
Date Signed: 01/28/2022 08:15:32 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/06/2021 and conducted by Evaluator Yangcheng Huang
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20211206155843
FACILITY NAME:CHI, LEWISFACILITY NUMBER:
434416673
ADMINISTRATOR:LEWIS CHIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 930-2778
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:14CENSUS: 0DATE:
12/16/2021
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Lewis ChiTIME COMPLETED:
12:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
PPE is not being worn on the facility grounds
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
*This amend is to change Complaint investigation report from Confidential to Public*

Licensing Program Analyst (LPA), Oscar Huang made a 10-day initial complaint investigation to the facility. LPA met with Licensee, Lewis Chi, and discussed the above allegation with him. LPA observed no chidren and staff as accoding to licensee that the facility is on holiday off since last Friday, 12/10/21 till the end of the year. LPA interviewed licensee, and copies of pertinent documents were also obtained.

Based on interview of Licensee for the complaint allegation listed above. LPA concludes that the preponderance of evidence standard has been met and the allegation listed above is therefore SUBSTANTIATED. Advisory Note -Technical Assistance is being issued on the attached LIC 9102.

Exit interview conducted with Licensee, Lewis Chi.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 DAYS.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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