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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216801961
Report Date: 01/09/2025
Date Signed: 01/09/2025 02:02:15 PM

Document Has Been Signed on 01/09/2025 02:02 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CAREMAX, INC. - QUIETWOOD HOMEFACILITY NUMBER:
216801961
ADMINISTRATOR/
DIRECTOR:
YANG, WEI & LI,JUANFACILITY TYPE:
735
ADDRESS:490 QUIETWOOD DRIVETELEPHONE:
(415) 225-6868
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 4CENSUS: 4DATE:
01/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Staff Member, Eric Deleon-Reyes, Licensee, Willie Yang, and Designated Representative, Agnes DizonTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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At approximately 9:30AM, Licensing Program Analysts (LPAs) Felias and Stevenson arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Eric Deleon-Reyes. Licensee, Willie Yang, and Designated Representative, Agnes Dizon, arrived during visit at approximately 10:50AM. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance for 1 ambulatory and 3 non-ambulatory clients with a total capacity for 4 Clients. Upon arrival, LPA was informed that there were 4 clients in care, and 2 staff members on-site.

LPAs reviewed Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPAs conducted a walk-though of the facility with Licensee. LPAs observed the following: Facility was clean with all exits free from obstruction. Facility had emergency lighting. Facility is a two story building with 4 Client bedrooms, 2 staff rooms, 3 bathrooms, and common areas. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to clients. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Mattress pads were in place or available for client use. LPAs observed that facility water was within Title 22 Regulations of 105-120F. Upon arrival, LPAs observed that the temperature was 65 degrees. LPAs discussed with Licensee on maintaining compliance with Title 22 regulation which states that facility temperature should be a minimum of 68F. LPA observed facility staff immediately set thermostat temperature to 70F (technical violation issued, see LIC9102, regulation 80088(a)(1)).

LPAs reviewed staff and client files, client medication, and P&I monies. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. P&I monies were documented, secure and not commingled. Medication was observed to be centrally stored and secure. Administrator's Certificate for Willie Yang (7032604735) was current with an expiration date of 10/16/2025. Fire extinguishers were last inspected October 2024. Smoke and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted December 2024.

Continued on LIC809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CAREMAX, INC. - QUIETWOOD HOME
FACILITY NUMBER: 216801961
VISIT DATE: 01/09/2025
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Continued from LIC809

LPAs requested the following documents to update facility file:
  • Affidavit regarding Client/Resident Cash Resources (LIC400)
  • Designation of Facility Responsibility (LIC308)
  • Emergency Disaster Plan (LIC610E)
  • Updated Personnel Report (LIC500)
  • Updated Surety Bond (LIC402)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate


Documents to be submitted to CCL by due date of 2/09/2025.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report, LIC9102 (Technical Advisory/Violation) discussed and provided to Licensee. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC809 (FAS) - (06/04)
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