<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200238
Report Date: 02/12/2025
Date Signed: 02/12/2025 10:58:26 AM

Document Has Been Signed on 02/12/2025 10:58 AM - 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:SNOW WHITE CARE HOMEFACILITY NUMBER:
435200238
ADMINISTRATOR/
DIRECTOR:		WANG, JAMESFACILITY TYPE:
740
ADDRESS:431 MUNDELL WAYTELEPHONE:
(650) 814-4400
CITY:LOS ALTOSSTATE: CAZIP CODE:
94022
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 1DATE:
02/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:James WangTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On February 12, 2025, at 08:50 AM, the Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. The LPA met with the caregiver, Merlita Bathan, and disclosed the purpose of the inspection. The caregiver informed the LPA that the facility had (1) resident in care and (1) staff member present at the time. The Licensee, James Wang, joined shortly after.

At 9:28 AM, the LPA initiated a walk-through of the facility, accompanied by the licensee.

LPA inspected the lobby room and observed it clean, with all furniture in good repair. LPA inspected the living room. There was a television, fireplace with a mesh screen, dining table, and dining chairs to accommodate the residents.

There were (6) bedrooms and (4) bathrooms designated for residents' use. All resident rooms were single occupancy. LPA inspected all (6) resident rooms and found them clean, well-lit, and equipped with the required furniture. LPA inspected (2) full bathrooms and found them clean, sanitary, and in good working condition. The bathrooms contained soap, grab bars, paper towels, a trash can, a shower chair, and non-slip mats. The hot water temperature at the sink faucet measured 118.6°F in bathroom #1 and 119.8°F in bathroom #2.

LPA inspected the kitchen and found it clean, with no cooking in progress at the time. The appliances were checked and observed to be in working order. The LPA inspected a locked cabinet containing knives and sharp objects, and a locked cabinet under the sink with detergents and cleaning supplies. The refrigerator and pantry cabinets were inspected, and sufficient supplies of fresh perishable food for (2) days and nonperishable staples for (7) days were observed. No expired food or stored medications were noted.

LPA inspected the fire extinguisher mounted on the wall in the kitchen and found it fully charged, with the last service tag dated 09/26/2024. The licensee tested the smoke and carbon monoxide detector located in the hallway in the LPA's presence, and it was found to be functional.

Continued on LIC809-C

April CowanTELEPHONE: (650) 266-8889
Kiran JainTELEPHONE: (650) 416-4836
DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2025
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: SNOW WHITE CARE HOME
FACILITY NUMBER: 435200238
VISIT DATE: 02/12/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA inspected the garage and found it clean. A washer, a dryer, and cabinets with incontinence supplies were observed.

LPA toured the backyard area and found ramps and passageways in good condition, clear of obstructions, with no blocking or tripping hazards. No bodies of water were noted. The LPA inspected (1) storage shed and observed wheelchairs, furniture items, bedframes, and mattresses, stored in the shed.

LPA reviewed (2) staff personnel records and (1) resident records. The LPA observed that 1 of 1 resident had an Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, and CSDMR. LPA observed that 2 of 2 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 2 of 2 staff members were associated with the facility.

LPA observed a locked centrally stored medication cabinet inside the kitchen. Medications were organized in separate bin for the resident. Centrally Stored Medication Records (CSMR) were reviewed and found to be complete.

LPA inspected the first aid kit and found it fully stocked. Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster Drills were conducted quarterly, with the most recent drill completed on 11/24/2024.

The following updated forms are requested to be submitted to CCLD by 02/19/2025:

  • LIC 500: Personnel Report
  • LIC 308: Designation of Facility Responsibility
  • Certificate of Liability Insurance
  • Current Control of Property (Lease or Deed) Document
  • Administrator Certificate(s)

No deficiencies were cited during today's visit.

An exit interview was conducted with the Licensee. A copy of this report was left with the Licensee, James Wang, whose signature on this form confirms receipt of the report.

SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran JainTELEPHONE: (650) 416-4836
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC809 (FAS) - (06/04)
Page: 2 of 2