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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
435202796
Report Date:
05/10/2023
Date Signed:
05/10/2023 05:11:53 PM
Document Has Been Signed on
05/10/2023 05:11 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, THE
FACILITY NUMBER:
435202796
ADMINISTRATOR:
WANG, YING
FACILITY TYPE:
740
ADDRESS:
329 EL PORTAL WAY
TELEPHONE:
(408) 618-5389
CITY:
SAN JOSE
STATE:
CA
ZIP CODE:
95119
CAPACITY:
6
CENSUS:
3
DATE:
05/10/2023
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
04:30 PM
MET WITH:
Tina Hsiu Luan Liu
TIME COMPLETED:
05:15 PM
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Licensing Program Analysts (LPAs) Trang Pham and Christine Dolores arrived unannounced to conduct a case management visit to deliver an amended report for facility visit on 4/27/2023. LPAs met with Tina Hsiu Luan Liu (Caregiver).
LPA T. Pham called and spoke to Administrator Ying Wang who stated she was unavailable to come to the facility and designated Tina Hsiu Luan Liu to sign off on the reports.
No deficiencies cited during today's visit.
This report was reviewed with Tina Hsiu Luan Liu and a copy of this report and the amended report was provided.
A copy of the appeal rights was also provided to Tina Hsiu Luan Liu.
SUPERVISORS NAME
:
Sarah Yip
LICENSING EVALUATOR NAME
:
Christine Dolores
LICENSING EVALUATOR SIGNATURE
:
DATE:
05/10/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/10/2023
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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