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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202503
Report Date: 04/29/2022
Date Signed: 04/29/2022 03:35:43 PM


Document Has Been Signed on 04/29/2022 03:35 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: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:
04/29/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:MADELINE TAM CHOWTIME COMPLETED:
09:50 AM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced final walk through for the facility closure, and met with Licensee (LNS) MADELINE TAM CHOW.

LPA toured the facility inside out with LNS. Living room, dinning room, kitchen, 4 bedrooms, 3 bathrooms and laundry room were observed and inspected. Backyard and front yard were observed and inspected. No deficiencies were observed. All the residents and staff transfer to new facility.

LNS stated all the resident files and staff files were transferred to the new owner.

Exit interview was conducted with LNS. This report was provided to LNS for signature.


SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022
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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