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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200466
Report Date: 07/28/2021
Date Signed: 07/29/2021 02:20:46 PM

Document Has Been Signed on 07/29/2021 02:20 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MADERA VILLA RESIDENTIAL CAREFACILITY NUMBER:
435200466
ADMINISTRATOR:TUAN, ALANFACILITY TYPE:
740
ADDRESS:1052 W. IOWA AVENUETELEPHONE:
(408) 739-7368
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY: 15CENSUS: 9DATE:
07/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Alan TuanTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced infection control site visit today. LPA met with the Licensee Alan Tuan.

One central entry point was designated for all staff, residents, and visitors. A temperature screening station, sign in sheet, and hand sanitizer were present at the entrance. LPA was temperature checked upon entry.

LPA toured the facility. The facility was observed to be in sanitary condition. Hand sanitizing stations were present. All staff were wearing face masks.

LPA inspected 2 restrooms. The restrooms were observed to be adequately stocked with paper towels and hand soap.

Facility was observed to have a sufficient supply of PPE in the storage area. A plan for epidemic outbreak specific to COVID-19 mitigation plan report (LIC 808) from the facility was in file. LPA discussed the infection control with the Licensee and made suggestions. 9 residents and all staff were fully vaccinated per Licensee.

Advisory notes (LIC 9102) were issued. No deficiency cited during visit.

This report was reviewed with the Licensee.

A copy of this report and advisory notes were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Yatfai Ng
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2021
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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