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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202796
Report Date: 12/21/2021
Date Signed: 12/21/2021 03:40:00 PM

Document Has Been Signed on 12/21/2021 03:40 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:MADISON HOUSE LLC, THEFACILITY NUMBER:
435202796
ADMINISTRATOR:WANG, YINGFACILITY TYPE:
740
ADDRESS:329 EL PORTAL WAYTELEPHONE:
(408) 618-5389
CITY:SAN JOSESTATE: CAZIP CODE:
95119
CAPACITY: 6CENSUS: 5DATE:
12/21/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Jenny McdonaldTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Steve Chang conducted a post licensing inspection visit, and met with licensee (LNS) Jenny Mcdonald. Upon arrival, staff Yanfang Manak (YM) took LPA body temperature, asked infection control questionnaires, and checked PA in the visitor log book.

LPA toured the facility inside out with LNS. There are 6 single bedrooms for residents, 1 staff live-in bedroom, and one and half bathrooms in facility. LPA toured the kitchen, dinning room, family room. Not all the trash cans with covers, not all the paper towels with holders, and no washing hands poster around the sinks. LNS stated the facility will fix these issues in 3 days. 2 days perishable food supplies and 7 days nonperishable food supplies were observed sufficient. Knives closet, medication closet, and cleaning product closet were observed locked. PPE supplies were observed sufficient. 5 residents and 4 staff were observed in facility. Laundry area and garage were inspected.

Room temperature was observed at 70 degree F, and hot water temperature degree was observed at 115 degree F. The facility equips with smoke/carbon monoxide detectors. LNS tested the smoke/carbon monoxide detectors, and they were working fine. The fire extinguisher was serviced on 11/22/2021. LPA toured the backyard with LNS. There was no obstruction to block the walkway.

LNS stated all the residents and staff are fully vaccinated, and done with booster shots.

No deficiency or citation was noted today. Exit interview was conducted with LNS. This report was provided to LNS for signature. A copy of this report was emailed to LNS.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2021
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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