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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202530
Report Date: 10/24/2022
Date Signed: 10/24/2022 12:08:10 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/24/2022 12:08 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
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:
10/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:52 AM
MET WITH:Xiuzhen FangTIME COMPLETED:
12:10 PM
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On 10/19/2022, Licensing Program Analyst Ryker Heberle (LPA) arrived at the facility unannounced to conduct an annual inspection. Upon arrival at the facility, there was nobody inside. LPA called the facility Administrator Xiuzhen Fang (Admin) to obtain more information. Admin stated that the facility doesn't currently have any residents. Admin stated they would call around to see if there was anybody available to let LPA into the facility. Admin later contacted facility Administrator Sarah Yip, and informed her that she would not be able to come back to the facility due to the a family member's hospitalization. LPM informed Admin that LPA would return later in the the coming days and that Admin needed to be ready to assist LPA with the inspection. Admin stated that she would do so.

LPA returned to the facility on 10/24/2022 at 10:52am to resume the inspection. LPA toured all rooms in the facility. During tour, LPA did not observe any evidence that care was being provided to any residents at the facility. Admin stated that she is still maintaining her license because she will resume admitting residents after she finishes arranging accommodations for her mother. LPA told Admin to inform licensing once she resume admitting residents.

No deficiencies cited during this inspection. LPA reviewed this report with facility administrator Xiuzhen Fang, and a copy of this report was provided. LPA concluded the inspection at 12:10pm.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
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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