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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202796
Report Date: 04/29/2022
Date Signed: 04/29/2022 11:17:42 AM

Document Has Been Signed on 04/29/2022 11:17 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
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: 6DATE:
04/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:31 AM
MET WITH:Tina LiuTIME COMPLETED:
11:32 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Tina Liu.

During visit, LPA Marrufo toured the inside and outside of the facility. LPA Marrufo observed a visitor screening area at the facility entrance. A PPE supply of at least 30-days was observed. A perishable food supply of at least 3 days and non-perishable food supply of at least 7 days were observed.

LPA Marrufo observed 2 out of 2 resident bathrooms and observed hand washing signs and available soap and paper towels.

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

This report was reviewed with Tina Liu and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2022
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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