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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202530
Report Date: 08/06/2024
Date Signed: 08/06/2024 11:14:51 AM


Document Has Been Signed on 08/06/2024 11:14 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:DOMA CARE HOMEFACILITY NUMBER:
435202530
ADMINISTRATOR:LI, XUANFACILITY TYPE:
740
ADDRESS:489 DOMA DRIVETELEPHONE:
(408) 335-6347
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY:6CENSUS: 0DATE:
08/06/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Xiuzhen FangTIME COMPLETED:
11:30 AM
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Licensing Program Analysts (LPAs) David Marrufo and Santino Fortes conducted an unannounced Case Management visit and met with Licensee Xiuzhen Fang.

During visit, LPAs toured 5 out of 5 bedrooms as well as the entire home. LPAs did not observe any residents or anyone else present in the facility besides the licensee who arrived to open the facility.

During visit, Licensee stated that there are no residents currently living or admitted in the facility and there are no staff at the facility.

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

This report was reviewed with Licensee Xiuzhen Fang and a copy of this report was provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024
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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