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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202415
Report Date: 06/14/2024
Date Signed: 06/14/2024 11:53:42 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/14/2024 11:53 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: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: 6DATE:
06/14/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Becky BiTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management - Annual Continuation visit and met with Administrator Becky Bi.

During visit, LPA Marrufo toured the kitchen area and garage area. LPA Marrufo observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. The garage area was locked and contained cleaning supplies. LPA Marrufo observed the first aid kit and found it to be complete.

LPA Marrufo toured the outside area and found the exits to be clear of obstructions.

LPA Marrufo reviewed the Centrally Stored Medications and Destruction Records and Resident Records for 6 out of 6 residents and found them to be complete. LPA Marrufo reviewed 3 staff files and found them to be complete.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Administrator Becky Bi and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024
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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