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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202510
Report Date: 12/19/2024
Date Signed: 12/19/2024 10:31:41 AM

Document Has Been Signed on 12/19/2024 10:31 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:FRIENDS OF CHILDREN WITH SPECIAL NEEDSFACILITY NUMBER:
435202510
ADMINISTRATOR/
DIRECTOR:		AI-CHING YEHFACILITY TYPE:
775
ADDRESS:1029 SOUTH BASCOM AVENUETELEPHONE:
(510) 739-6900
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 90CENSUS: 54DATE:
12/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Vivian Chung and Jake HawTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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On December 19, 2024, at 8:30 AM, Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. LPA met with the Program Coordinator (PC), Jake Haw and disclosed the purpose of the inspection. Program Director (PD), Vivian Chung arrived shortly after. Clients and staff were seen arriving at the facility. Temperature check was done on arrival for both staff and clients.

LPA toured the physical plant along with PC and observed it to be clean and odor-free at a comfortable temperature and adequate lighting. LPA inspected (2) classrooms, multipurpose room, computer room, office room, and training room. Clients were observed engaged in exercising activity in the main multipurpose room. Training room is used for making soaps, pottery, baking and folding clothes activities. Multipurpose room is used for dancing, exercise, arts, crafts, and music activities. LPA inspected hallways and passageways and no obstructions were observed. No accessible bodies of water or fire safety/tripping hazards were observed.

LPA inspected the kitchen and observed sharp objects were stored/locked properly inside a locked safe box placed inside the locked pantry and inaccessible to the clients. No cooking was observed. The PC mentioned that clients bring their lunch/snack and staff helps the clients to microwave their food. LPA inspected the refrigerator and observed staff and client’s food inside.

The gender specific bathrooms were observed to be clean and equipped with trash cans, grab bars, liquid soap, and paper towels. The hot water temperature was measured in (1) bathroom at 105.2°F.

LPA reviewed 5 random client files and 5 random staff files. The LPA observed that 5 of 5 clients had the Admission Agreement, Physician's Report, Appraisal Needs and Services Plan. LPA observed that 5 of 5 staff members had First Aid/CPR training, LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 5 of 5 staff members are associated with the facility.

Continued on 809-C

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: FRIENDS OF CHILDREN WITH SPECIAL NEEDS
FACILITY NUMBER: 435202510
VISIT DATE: 12/19/2024
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The client’s medications were securely stored in a lock box inside the office room. All medication bottles were properly labeled. LPA inspected the first aid kit and observed it fully stocked.

Fire extinguishers were observed fully charged and last serviced on 08/27/2024. Smoke detectors with sprinklers were observed. The PC tested the carbon monoxide detector located in the kitchen in the LPA's presence, and it was found to be functional. LPA reviewed Emergency Drill Logs and observed drills are conducted every other month, with the most recent fire drill completed on 10/25/2024.

The following updated forms are requested to be submitted to CCLD by 12/26/2024:

  • LIC 500: Personnel Report
  • LIC 308: Designation of Facility Responsibility
  • Certificate of Liability Insurance

No deficiencies were cited during today's visit.

An exit interview was conducted. A copy of this report was left with the Program Director, Vivian Chung, whose signature on this form confirms receipt of the report.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Kiran Jain
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC809 (FAS) - (06/04)
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