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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200466
Report Date: 07/07/2025
Date Signed: 07/07/2025 01:06:44 PM

Document Has Been Signed on 07/07/2025 01:06 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:MADERA VILLA RESIDENTIAL CAREFACILITY NUMBER:
435200466
ADMINISTRATOR/
DIRECTOR:		TUAN, ALANFACILITY TYPE:
740
ADDRESS:1052 W. IOWA AVENUETELEPHONE:
(408) 739-7368
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY: 15CENSUS: 12DATE:
07/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Alan TuanTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
NARRATIVE
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On July 07, 2025, 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 Administrator, Alan Tuan, and disclosed the purpose of the inspection. The Administrator informed the LPA that the facility had (12) residents in care and (3) staff members present at the time.

At 8:55 AM, the LPA initiated a walk-through of the facility, accompanied by the Administrator. The indoor temperature reading of 75°F on a thermostat was observed in the hallway at the time of the visit.

LPA inspected the kitchen and observed breakfast service was in progress at the time. The appliances were checked and observed to be in working order. The LPA observed a locked lock box on the kitchen countertop containing knives and sharp objects. LPA inspected a locked cabinet under the sink containing detergents, disinfectants, and cleaning supplies. The refrigerator and pantry cabinets were inspected, and sufficient supplies of fresh perishable food for two (2) days and nonperishable staples for seven (7) days were observed. No expired food or stored medications were noted.

LPA inspected the dining area adjacent to the kitchen. One (1) resident was observed to be sitting in the dining area eating breakfast. LPA inspected the living room and observed a sofa, chairs, tables, a piano, and a television in the living room. Two (2) residents were observed sitting in the living room watching TV. Board games, puzzles, arts, coloring, bingo, and other recreational activity items for residents’ activities were also observed in the living room.

LPA inspected the fire extinguisher mounted on the wall in the hallway and found it fully charged, with the last service tag dated 07/10/2024. The Administrator tested the smoke and carbon monoxide detector located in the office room in the LPA's presence, and it was found to be functional.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: MADERA VILLA RESIDENTIAL CARE
FACILITY NUMBER: 435200466
VISIT DATE: 07/07/2025
NARRATIVE
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There were fifteen (15) bedrooms designated for residents' use. All (15) resident rooms were single occupancy. LPA inspected random six (6) resident rooms and found them clean, well-lit, and equipped with the required furniture. LPA inspected half bathrooms in these random rooms and found them in working condition. The bathrooms contained soap, grab bars, towels, and a trash can. The hot water temperature at the sink faucet measured between 118.2°F to 119.5°F in these bathrooms. LPA observed men and women bathrooms in the hallway for shower with a shower chair, non-slip mats, and grab bars.

LPA observed a laundry area in the hallway with a washer and a dryer. The laundry detergents, cleaning solutions, and disinfectants, were observed locked in a closet next to the backside door. LPA inspected a dresser in the hallway and observed it containing clean linen supplies.

LPA toured the backyard area and found ramps and passageways in good condition, clear of obstructions, with no blocking or tripping hazards. The backyard had a set of a patio table, chairs, and a gazebo for resident use. No accessible bodies of water were found. LPA inspected one (1) storage shed and observed refrigerators, freezers, and pantry food items stored in the shed.

At 10:25 AM, LPA reviewed five (5) staff personnel records and five (5) resident records. The LPA observed that 5 of 5 residents had an Admission Agreement and current Physician's Report. LPA observed that 3 of 5 residents did not have Pre-Admission Appraisal, 5 of 5 residents didn’t have Functional Capabilities Assessment, and 4 of 5 residents didn’t have current Appraisal Needs and Services Plan. LPA observed that 5 of 5 staff members had LIC 508 Criminal Record Statements, LIC 503 Health Screening, current first aid certificates, and confirmed that 5 of 5 staff members were associated with the facility.

LPA observed a locked centrally stored medication cabinet located inside in the hallway near the backside door. Medications were organized separately for each resident. All medication bottles and bubble packs were properly labeled. Centrally Stored Medication Records were reviewed and found to be complete.

At 11:35 AM, LPA asked the Administrator for an Emergency Disaster Drill log. The Administrator didn’t have Emergency Disaster Drills logs for LPA to review, and LPA was not able to verify if the drills are conducted quarterly at the facility.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025
LIC809 (FAS) - (06/04)
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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: MADERA VILLA RESIDENTIAL CARE
FACILITY NUMBER: 435200466
VISIT DATE: 07/07/2025
NARRATIVE
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LPA inspected the first aid kit and found it fully stocked.

The following updated forms are requested to be submitted to CCLD by 07/14/2025:

  • LIC 500: Personnel Report
  • LIC 308: Designation of Facility Responsibility
  • Certificate of Liability Insurance
  • Administrator Certificate(s)

The deficiencies are being cited based on LPA observations, records reviewed, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted, and Plans of Correction were reviewed and developed with the Administrator. A copy of this report and appeal rights were discussed and provided to the Administrator, Alan Tuan, whose signature on this form confirms receipt of these documents.

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/07/2025 01:06 PM - It Cannot Be Edited


Created By: Kiran Jain On 07/07/2025 at 12:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: MADERA VILLA RESIDENTIAL CARE
FACILITY NUMBER: 435200466

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(17)(A)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (A) Section 87457, Pre-Admission Appraisal;

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review and interview, the Administrator did not ensure that 3 of 5 residents (R3-R5) have Pre-Admission Appraisal done, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2025
Plan of Correction
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2
3
4
The Administrator will submit a plan of correction to CCLD by 07/14/2025.
Type B
Section Cited
CCR
87506(b)(17)(B)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (B) Section 87459, Functional Capabilities;

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the Administrator did not ensure that 5 of 5 residents (R1-R5) have Functional Capabilities assessment done, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2025
Plan of Correction
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The Administrator will submit a plan of correction to CCLD by 07/14/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Kiran Jain
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/07/2025 01:06 PM - It Cannot Be Edited


Created By: Kiran Jain On 07/07/2025 at 12:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: MADERA VILLA RESIDENTIAL CARE
FACILITY NUMBER: 435200466

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)(3)
Resident Participation in Decisionmaking
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the Administrator did not ensure that 4 of 5 residents (R2-R5) have current Appraisal Needs and Service Plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2025
Plan of Correction
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The Administrator will submit a plan of correction to CCLD by 07/14/2025.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Kiran Jain
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/07/2025 01:06 PM - It Cannot Be Edited


Created By: Kiran Jain On 07/07/2025 at 12:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: MADERA VILLA RESIDENTIAL CARE
FACILITY NUMBER: 435200466

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the Administrator did not ensure that the Emergency Disaster Drills logs are available for review and hence LPA was not able to verify if the drills are conducted quarterly at the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2025
Plan of Correction
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2
3
4
The Administrator will submit a plan of correction to CCLD by 07/14/2025.
Section Cited
Deficient Practice Statement
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2
3
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POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Kiran Jain
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2025


LIC809 (FAS) - (06/04)
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