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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202796
Report Date: 06/14/2024
Date Signed: 06/14/2024 12:55:16 PM


Document Has Been Signed on 06/14/2024 12:55 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: DATE:
06/14/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Hsiu Luan LiuTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management – other visit. LPA met with lead caregiver Hsiu Luan "Tina" Liu.

The purpose of the visit was to deliver an amended report for complaint control number 26-AS-20240208125557.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with lead caregiver Hsiu Luan "Tina" Liu and a copy of the report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Christine DoloresTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2024
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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