<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435294286
Report Date: 09/28/2024
Date Signed: 09/28/2024 11:02:06 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/27/2023 and conducted by Evaluator Simranjit Rai
COMPLAINT CONTROL NUMBER: 26-AS-20230727120329
FACILITY NAME:WILLIE CARE HOME IIFACILITY NUMBER:
435294286
ADMINISTRATOR:ZHAO, WUSHENGFACILITY TYPE:
740
ADDRESS:1136 SOUTH MARY AVENUETELEPHONE:
(408) 749-8758
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:6CENSUS: 6DATE:
09/28/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Guili "Penny" XuTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Medication is accessible to residents.
Hazardous chemicals are accessible to resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Administrator, Guili "Penny" Xu and stated the purpose of today’s visit.

On 7/27/2023, the Department received a complaint with the above allegations. On 8/1/2023, the Department conducted an initial investigation at the facility.

Continuation on LIC 9099-C, Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 26-AS-20230727120329
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: WILLIE CARE HOME II
FACILITY NUMBER: 435294286
VISIT DATE: 09/28/2024
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 of 2.

Medication is accessible to residents.
It was alleged medication was left in the refrigerator unlocked and accessible to residents.

During visit on 8/1/2023, LPA observed medication for R1 unlocked and accessible in the fridge located in the office. The medications were not locked into the fridge and the fridge did not have locking capabilities. The fridge was located in the office and the office door was not locked. LPA observed 1 resident walking around the facility.

Hazardous chemicals are accessible to resident.
It was alleged chemicals is unlocked and accessible to residents.

During visit on 8/1/2023, LPA observed laundry detergent on the dryer machine, which was located in the office. The office door was not locked, and the laundry detergent was not locked and accessible to residents. LPA observed Clorox Disinfecting wipes in the living room, unlocked and accessible to residents. LPA observed 1 resident walking around the facility.

Based on interviews and observation/inspection of the facility, the preponderance of evidence standard has been met therefore the above allegations is found to be SUBSTANTIATED.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D.
This report was reviewed with Administrator and a copy of the report was provided. Appeal Rights was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 26-AS-20230727120329
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: WILLIE CARE HOME II
FACILITY NUMBER: 435294286
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/29/2024
Section Cited
CCR
87465(h)(2)
1
2
3
4
5
6
7
87465(h)(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator submitted a written Plan of Correction to LPA Rai during investigation and LPA Rai cleared the deficiency during today's visit.
8
9
10
11
12
13
14
Based on observation, Licensee did not ensure medication in the fridge were locked that is not accessible to residents in care which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
8
9
10
11
12
13
14
Type A
09/29/2024
Section Cited
CCR
87309(a)
1
2
3
4
5
6
7
87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator submit a written Plan of Correction to LPA Rai during investigation and LPA Rai cleared the deficiency during today's visit.
8
9
10
11
12
13
14
Based on observation, Licensee did not ensure laundry detergents and Clorox Disinfecting wipes were stored where inaccessible to residents which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/27/2023 and conducted by Evaluator Simranjit Rai
COMPLAINT CONTROL NUMBER: 26-AS-20230727120329

FACILITY NAME:WILLIE CARE HOME IIFACILITY NUMBER:
435294286
ADMINISTRATOR:ZHAO, WUSHENGFACILITY TYPE:
740
ADDRESS:1136 SOUTH MARY AVENUETELEPHONE:
(408) 749-8758
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:6CENSUS: 6DATE:
09/28/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Guili "Penny" XuTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not ensure that residents are adequately fed.
Staff does not serve a variety of foods.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Administrator, Guili "Penny" Xu and stated the purpose of today’s visit.

On 7/27/2023, the Department received a complaint with the above allegations. On 8/1/2023, the Department conducted an initial investigation at the facility.

Continuation on LIC 9099-C, Page 1 of 3.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 26-AS-20230727120329
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: WILLIE CARE HOME II
FACILITY NUMBER: 435294286
VISIT DATE: 09/28/2024
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 of 3.

Staff does not ensure that residents are adequately fed.
It was alleged residents were only served breakfast and dinner.

On 8/1/2023, the Department interviewed 2 staff (S1-S2). Two of two staff stated the residents are adequately fed and staff will always ask their preference for food. S1 and S2 stated R1 will only have two meal, breakfast, and dinner, per the resident’s preference.

On 8/1/2023, the Department interviewed 5 residents (R1-R5). One resident was not available for interview. One out of 4 residents stated the facility staff provide 3 meals and snacks when residents are hungry.

During visit on 8/1/2023, LPA observed 2 days of perishable foods and 7 days of perishable foods. LPA observed resident were served breakfast which included waffle, egg, toast, coffee, juice and yogurt parfait with fresh bananas and strawberries. LPA observed residents were served lunch which included spaghetti with meatballs, garlic bread, cantaloupe, juice and pound cake.

Based on receipts for groceries purchased from 06/01/2023- 07/19/2023, the facility staff are provided quantity and quality of food to feed the residents at the facility at least 7 days to include 3 meals and snacks each day.

Staff does not serve a variety of foods.
It was alleged residents only served Filipino food at the facility.

On 8/1/2023, the Department interviewed 2 staff (S1-S2). One of two staff stated they serve a variety of food, which includes Filipino food and Chinese food. S1 stated the staff will ask the residents how they want the food prepared and they will change the type of protein each day such as one day will be a chicken entrée and the next day will be a pork entrée. S1 stated each meal is served with vegetables, fruit, and yogurt. S2 stated the staff will always make Filipino food and the resident will eat what they are being served.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 26-AS-20230727120329
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: WILLIE CARE HOME II
FACILITY NUMBER: 435294286
VISIT DATE: 09/28/2024
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 3 of 3.

On 8/1/2023, the Department interviewed 3 residents (R1-R3). Three out of three residents stated the facility staff provide 3 meals and snacks when residents are hungry. R2 stated the variety of food is okay but would like something different.

During visit on 8/1/2023, LPA observed resident were served breakfast which included waffle, egg, toast, coffee, juice and yogurt parfait with fresh bananas and strawberries. LPA observed residents were served lunch which included spaghetti with meatballs, garlic bread, cantaloupe, juice, and pound cake.

Based on the interviews conducted with residents and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator, Guili "Penny" Xu and a copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6