<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202530
Report Date: 08/09/2024
Date Signed: 08/12/2024 01:26:24 PM


Document Has Been Signed on 08/12/2024 01:26 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:
08/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Licensee, Xiuzhen FangTIME COMPLETED:
10:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Simi Rai and Steve Change conducted an unannounced case management visit at the facility. LPAs called Licensee, Xiuzhen Fang to arrive at the facility to conduct a walk-through, but Licensee refused. Licensee stated for LPAs to jump over the perimeter gate since the front door is unlocked. Licensee stated there are cameras at the facility.

LPAs toured the outside perimeter of the facility. LPAs did not observe staff or residents present in the facility. During last visit on 8/6/2024, LPAs did a walk-through of the facility and did not observe staff or residents present at the facility. The facility was non-operational.

The Department served the facility with a Temporary Suspension Order (TSO) effective 8/6/2024 and the facility did not have any residents to relocate.

Licensee refused to arrive at the facility and Licensee refused to sign the report.

A copy of the report will be certified mailed to Licensee's mailing address.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2024
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 1