435202957-3-25-2026-26-AS-JVAO-DSHLJP-20260325084813

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202957
Report Date: 03/24/2026
Date Signed: 03/25/2026 08:48:19 AM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/25/2026 08:48 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	BROMPTON RESIDENTIAL CARE LLC		FACILITY NUMBER:	435202957
ADMINISTRATOR/ DIRECTOR:	WANG, YING		FACILITY TYPE:	740
ADDRESS:	858 REVERE DR		TELEPHONE:	(408) 605-1680
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY: 6		CENSUS: 6	DATE:	03/24/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Administrator - Ying Wang		TIME VISIT/ INSPECTION COMPLETED:	02:00 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On 03/24/2026, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required annual 1 year inspection visit. LPA met with the Administrator Ying Wang and explained the purpose of today's visit. During today's visit there are 5 residents present and 1 is in the hospital due to medical condition. There are 2 staff present including the administrator.

This is a single level facility. This facility is licensed for 6 residents, 60 and over, whom all may be non-ambulatory. Hospice waiver on file for 2 residents. During today's visit there is 1 resident on hospice. LPA inspected the kitchen and found it clean, with breakfast preparation and cooking in progress at the time. Lunch was also being prepared for cooking. The appliances were checked and observed to be in working order. LPA inspected a locked drawer that contained knives and sharp objects are stored. Below the kitchen sink cleaning supplies are observed to be locked and not accessible to residents. Resident medications are locked as well in an upper cabinet in the kitchen. The refrigerator and pantry cabinets are inspected as sufficient in supplies of fresh perishable food for (2) days and nonperishable staples for (7) days were observed. No expired food or stored medications were noted in the refrigerator. The living room area is observed as clean, with all furniture in good repair. There is a sofa set, television, fireplace, and piano in the living room. LPA observed a fire extinguisher mounted on the wall in the living room with a purchase date of 01/24/2026. Facility has a hard wired combination smoke and carbon monoxide detectors as well as fire sprinklers through out. There is a fire pull station observed in the living room as well.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Cara Smith
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/24/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026

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 3

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)

Page: 2 of 3

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: 03/24/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Page 2

There are 6 bedrooms for residents, and one staff room. There are 2 common full bathrooms for resident use. All 6 resident rooms are single occupancy and are found to be clean, well-lit, and equipped with the required furniture outlined in Title 22. In the hallway connecting to to all resident rooms, there are closets designated for resident supplies such as incontinence care, linens, and incidental supplies. LPA inspected bathrooms and found them clean, sanitary, and in good working condition. The bathrooms contained soap, grab bars, paper towels, a trash can, a shower chair, and non-slip flooring. Water temperature is tested in two resident restrooms at 118F. The garage contains the washer, dryer, a refrigerator, a freezer containing additional food supplies. Cleaning supplies are observed as well located in the garage which is locked. A walk around of the outside perimeter and the backyard is conducted, and is observed as safe with fencing in place, no hazardous items or materials, and emergency exit routes are free and clear of any obstructions. There are two storage sheds observed as locked and housing gardening supplies and other items.

LPA reviewed resident and staff records and found both to be current and complete. Staff training is in place and first aid cards are present. Last fire drill conducted was on 01/07/2026 per records observed, which was a fire drill that took place. LPA inspected the first aid kit and found it fully stocked as well during today's visit. Medications and its records are observed to be current and logged accurately.

LIC500 Personnel Report
LIC308 Designation of Facility Responsibility
Certificate of Liability Insurance
Copy of Administrator Certificate.

No citations issued on this day. Technical Assistance is provided and can be foundon the the attached LIC9102TA. Report is reviewed with administrator Ying Wag and a copy is provided.

NAME OF LICENSING PROGRAM MANAGER: Cara Smith
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/24/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026

LIC809 (FAS) - (06/04)

Page: 3 of 3