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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200466
Report Date: 07/26/2022
Date Signed: 07/26/2022 10:52:35 AM


Document Has Been Signed on 07/26/2022 10:52 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: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: 12DATE:
07/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Alan TuanTIME COMPLETED:
11:00 AM
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On 07/26/2022, Licensing Program Analyst (LPA) Mandeep Kaur and Licensing Program Manager (LPM) Sarah Yip conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Alan Tuan, Administrator. Upon entrance of the facility, LPA's and LPM's temperature was measured.
LPA and LPM toured the facility inside and out. Sharp objects, toxins, cleaning supplies are secured. Medications are stored in a locked cabinet in the office.

Facility observed to have designated entry point for COVID 19 symptom screening. Hand sanitizer available to visitors and residents. Bathrooms observed to be supplied with hygiene products.

Foot operated trash containers observed in the bathrooms and in the kitchen. LPA observed supply of Personal Protective Equipment (PPE).
The main kitchen was inspected. There was sufficient perishable food for at least 2 days and nonperishable food for at least one week.
All staff members were observed to be wearing masks.

No citations were issued per the California Code of Regulations Title 22.

LPA will email the administrator to provide the Copy of LIC 610 with 2 facilities listed under Section IV (Temporary Relocation site(s)) and infection Control plan.


LPA reviewed report with Alan Tuan, Administrator and a copy provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Mandeep KaurTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
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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