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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202796
Report Date: 02/15/2024
Date Signed: 02/15/2024 01:04:23 PM

Document Has Been Signed on 02/15/2024 01:04 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: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: 6DATE:
02/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Hsiuluan "Tina" LiuTIME COMPLETED:
01:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to open an initial complaint investigation. During visit, a violation was observed therefore, a case management - deficiencies visit was conducted. LPA met with caregiver / designated Administrator (ADM), Hsiuluan "Tina" Liu.

During visit, LPA observed 1 staff member (S1) working and assisting residents. LPA observed S1's background check is "pending" determination per the facility's personnel print out from 02/14/2024. S1 states he/she went to get fingerprinted, however, S1 has not received a fingerprint clearance. Designated ADM states S1 went to get fingerprinted on Monday, 02/12/2024 and started work on Monday, 02/12/2024. Designated ADM admits S1 has not received a fingerprint clearance from the Department.

LPA reviewed the Departments Background Clearance System during visit, which shows S1's background clearance is still "in process". Designated ADM immediately released S1 from work. S1 was informed he/she cannot work in the facility until S1 receives a fingerprint clearance from the Department. LPA Dolores spoke with Administrator (ADM), Ying Wang over the telephone regarding S1's fingerprint clearance. ADM states going forward they will make sure staff receive a fingerprint clearance before starting work.

A deficiency is being cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty is being assessed for the amount of $400 ($100 x 4 days) = $400 for S1 working in the facility without a fingerprint clearance. See LIC421BG. This report was reviewed with Administrator, Ying Wang over the telephone. A copy of the report was signed by Tina Liu. The report and appeal rights were provided to Tina.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2024
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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Document Has Been Signed on 02/15/2024 01:04 PM - It Cannot Be Edited


Created By: Christine Dolores On 02/15/2024 at 12:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: MADISON HOUSE LLC, THE
FACILITY NUMBER: 435202796

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/16/2024
Section Cited
CCR
87366(e)(1)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or ... This requirement is not met as evidenced by:
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Licensee will submit a statement of understanding is section 87633 to LPA Dolores via email by POC due date.
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Based on interview, record review and observation the licensee did not ensure staff (S1) was fingerprint cleared prior to starting work on 02/12/2024 which poses an immediate health, safety, and personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024


LIC809 (FAS) - (06/04)
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