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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294286
Report Date: 01/19/2024
Date Signed: 04/24/2024 02:36:12 PM


Document Has Been Signed on 04/24/2024 02:36 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



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:
01/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:58 PM
MET WITH:Guili XuTIME COMPLETED:
04:59 PM
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Licensing Program Analysts (LPAs) Steve Chang Mita Partoza conducted an unannounced annual inspection visit, and met with Administrator (ADM) Guili Xu. License, personal rights posters and Administrator Certificate were observed at the entrance.

LPAs reviewed 3 residents files and 3 staff files..

LPA toured the facility inside out with ADM. Living room, kitchen, dinning room and four restrooms were inspected. Six single resident bedrooms, and laundry room were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 71 degree F, and hot water temperature was at 119 degree F in facility. Six residents (R1 - R6) and two staff (S1, S2) were interviewed.

Fire extinguisher was serviced on 4/24/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

Annual inspection will be continued at a later date.

Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024
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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