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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202957
Report Date: 08/04/2025
Date Signed: 08/04/2025 12:45:53 PM

Document Has Been Signed on 08/04/2025 12:45 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:BROMPTON RESIDENTIAL CARE LLCFACILITY NUMBER:
435202957
ADMINISTRATOR/
DIRECTOR:		WANG, YINGFACILITY TYPE:
740
ADDRESS:858 REVERE DRTELEPHONE:
(408) 605-1680
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY: 6CENSUS: 4DATE:
08/04/2025
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Ying WangTIME VISIT/
INSPECTION COMPLETED:
12:55 PM
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On August 04, 2025, the Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Post Licensing inspection. The LPA met with the Licensee, Ying Wang, and disclosed the purpose of the inspection. The Licensee informed the LPA that the facility had four (4) residents in care and one (1) additional staff member present at the time.

LPA initiated a walk-through of the facility, accompanied by the Licensee. The indoor temperature reading of 68°F on a thermostat was observed in the hallway at the time of the visit.

LPA inspected the kitchen and observed lunch preparation and cooking in progress at the time. The appliances were checked and observed to be in working order. The LPA inspected a magnetic locked cabinet containing knives and sharp objects. LPA inspected another magnetic locked cabinet under the sink with detergents, disinfectants, and cleaning supplies. The refrigerator and pantry cabinets were inspected, and sufficient supplies of fresh perishable food for (2) days and nonperishable staples for (7) days were observed. No expired food or stored medications were noted. LPA observed the refrigerator temperature at 37°F and freezer temperature at 0°F.

LPA inspected the dining area adjacent to the kitchen. The dining table and chairs were observed to accommodate the residents, and all the furniture was in good repair. LPA inspected the living room and observed a sofa set, chairs, a fireplace, and a television in the living room. One (1) resident was observed sitting in the living room watching TV.

LPA observed three (3) hallway closets, one linen closet with bedsheets, blankets, and towels, second closet containing incontinent supplies, and the third closet with toiletries.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: BROMPTON RESIDENTIAL CARE LLC
FACILITY NUMBER: 435202957
VISIT DATE: 08/04/2025
NARRATIVE
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There were six (6) bedrooms, three (3) full bathrooms, and one (1) half bathroom designated for residents' use. All (6) resident rooms were single occupancy. LPA inspected all (6) resident rooms and found them clean, well-lit, equipped with the required furniture. Four (4) rooms had a sliding door exit to the outside deck/backyard access. The bathrooms contained soap, grab bars, towels, a trash can, a shower chair, and non-slip mats/flooring. The hot water temperature at the sink faucet measured between 115.8°F to 117.5°F in all bathrooms.

The LPA inspected the laundry area and observed a washer and a dryer. LPA observed a locked cabinet in the laundry area containing detergents, disinfectants, and cleaning supplies. LPA inspected a locked staff break room in the garage and observed sofa, table, and chairs preset in the break room.

LPA inspected the fire extinguisher mounted on the wall in the hallway and found it fully charged, with the last service tag dated 10/13/2024. The Licensee tested the carbon monoxide detector located in the hallway in the LPA's presence, and it was found to be functional. Additional smoke detectors were observed in all bedrooms and common areas of the facility during the visit.

LPA toured the backyard area and found ramps and passageways in good condition, clear of obstructions, with no blocking or tripping hazards. No accessible bodies of water were found. The backyard had a table, chairs, and shaded areas for resident use.

LPA observed a magnetic locked centrally stored medication cabinet located inside in the dining area. Medications were organized separately for each resident. All medication bottles were properly labeled. Centrally Stored Medication Records were reviewed and found to be complete. Medication count was found to be accurate.

LPA inspected the first aid kit and found it fully stocked. LPA reviewed Emergency Drill Logs and observed Emergency Disaster Drills were conducted quarterly, with the most recent drill completed on 06/23/2025.

LPA reviewed three (3) staff personnel records and four (4) resident records. The LPA observed that 4 of 4 residents had the Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, Consent forms, Safeguard personal property and valuables, and Personal rights forms. LPA observed that 3 of 3 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: BROMPTON RESIDENTIAL CARE LLC
FACILITY NUMBER: 435202957
VISIT DATE: 08/04/2025
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The following updated forms are requested to be submitted to CCLD by 08/11/2025:
  • LIC 500: Personnel Report
  • LIC 308: Designation of Facility Responsibility

No deficiencies were cited during today's visit.

An exit interview was conducted with the Licensee. A copy of this report was provided to the Licensee, Ying Wang, whose signature on this form confirms receipt of the report.

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4