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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202415
Report Date: 06/10/2022
Date Signed: 06/10/2022 04:25:35 PM


Document Has Been Signed on 06/10/2022 04:25 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:CASA ALICE CARE HOMEFACILITY NUMBER:
435202415
ADMINISTRATOR:PING JING ZHAOFACILITY TYPE:
740
ADDRESS:809 ALICE AVENUETELEPHONE:
(650) 279-7488
CITY:MOUNTAIN VIEWSTATE: CAZIP CODE:
94040
CAPACITY:6CENSUS: 5DATE:
06/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Becky BiTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Becky Bi.

During visit, LPA Marrufo toured the facility. LPA Marrufo observed a visitor screening area with a thermometer. LPA Marrufo observed the facility bathroom had hand washing posters and available soap and paper towels. LPA Marrufo observed there to be a PPE supply of at least 30 days. LPA observed a perishable food supply of at least 2 days and a non-perishable food supply of at least 7 days.


No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Becky Bi and a copy of the report was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022
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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