435201626-8-3-2023-26-AS-KHOS-CURNMX-20230816103551

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435201626
Report Date: 08/03/2023
Date Signed: 08/03/2023 03:19:51 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/27/2023 and conducted by Evaluator Christine Dolores

COMPLAINT CONTROL NUMBER: 26-AS-20230727113159

FACILITY NAME:	WILLIE CARE HOME		FACILITY NUMBER:	435201626
ADMINISTRATOR:	ZHAO,WUSHENG		FACILITY TYPE:	740
ADDRESS:	1194 SOUTH MARY AVE.		TELEPHONE:	(408) 749-0823
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY:	6	CENSUS: 6	DATE:	08/03/2023
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Whusheng Zhao		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Staff do not ensure that residents are adequately fed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to open the initial complaint investigation. LPA met with Administrator (ADM), Whusheng Zhao.

On 07/27/2023, the Department received the complaint. On 08/03/2023, the initial complaint investigation was conducted.

During visit, LPA toured the facility with ADM to include the kitchen, dining room, living room, garage, bedrooms, bathroom, laundry room, and exterior. LPA observed 6 out of 6 residents. LPA attempted to interview 2 out of 6 residents.

LPA interviewed 2 out of 2 staff members. Based on interview, the facility serves 3 meals a day and provide snacks anytime throughout the day. The facility serves a variety of food options to include protein, fruits and vegetables. The facility purchases groceries at least once a week. SEE LIC9099-C.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20230727113159

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: WILLIE CARE HOME	FACILITY NUMBER: 435201626
	VISIT DATE: 08/03/2023

NARRATIVE

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Based on observation, the facility has a sufficient food supply to include a variety of vegetables, meats, protein, fruits, grains, dessert, juice, dairy, water, and non-perishable foods.

Documents were obtained to include the facility’s resident roster, grocery shopping receipts from May – July 2023, and the facility menu.

The review of records show the facility purchases a variety of food items multiple times a month for the facility. The ADM states the groceries are shared with another facility owned by the Licensee.

The Department has investigated the above allegation. Based on interview, record review and observation the above allegation is unfounded, meaning the allegation is false, could not have happened, and/or is without a reasonable basis. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Whusheng Zhao and a copy of the report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine Dolores	TELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

LIC9099 (FAS) - (06/04)

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