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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202503
Report Date: 11/23/2021
Date Signed: 11/23/2021 02:50:27 PM

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:HEALTHY LIVING RESIDENTIAL CARE HOMEFACILITY NUMBER:
435202503
ADMINISTRATOR:MADELINE TAM CHOWFACILITY TYPE:
740
ADDRESS:251 DELIA STREETTELEPHONE:
(408) 493-6955
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:6CENSUS: 5DATE:
11/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Xiuyan Chen, ADMTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with administrator (ADM) Xiuyan Chen. Upon arrival, staff Mercedita Molina (MM) took LPA body temperature, asked the infection control questionnaires, and checked LPA in the visitor log book.

Screening station with gloves, hand sanitizer, thermometer, masks, and visitor log book were observed at main entrance. LPA toured the facility inside out with ADM. Living room, kitchen, dinning room, and 2 restrooms were inspected. Not all the trash cans are with covers. ADM stated the facility will change the trash cans to be with covers in 3 days. ADM stated the facility will put more paper towels with holds, and disinfect wipes in facility. There are three shared resident rooms in facility. Two staff and 5 residents were observed in facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, cleaning product closet, and knives closed were observed locked. Room temperature was at 68 degree F, and hot water temperature was at 113 degree F.

Fire extinguisher was serviced on 09/30/2021. The facility was equipped with smoke and carbon monoxide detectors. Front yard and backyard were inspected. There was no obstruction observed to block the walkways.

ADM stated the new application is currently under processing. ADM stated ADM owns an administrator certificate for ARF, and ADM just passed the administrator exam for RCFE. ADM stated the RCFE administrator certificate is currently under processing. ADM stated all the residents and staff are fully vaccinated.

No deficiency or citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was emailed to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
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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