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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200238
Report Date: 02/03/2022
Date Signed: 02/03/2022 10:15:11 AM

Document Has Been Signed on 02/03/2022 10:15 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SNOW WHITE CARE HOMEFACILITY NUMBER:
435200238
ADMINISTRATOR:WANG, JAMESFACILITY TYPE:
740
ADDRESS:431 MUNDELL WAYTELEPHONE:
(650) 814-4400
CITY:LOS ALTOSSTATE: CAZIP CODE:
94022
CAPACITY: 6CENSUS: 4DATE:
02/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:James WangTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with James Wang and Merlita Bathan.

During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo observed two out of two hallway bathrooms had hand washing signs. The hallways had COVID-19 related posters. The facility entrance had a COVID-19 visitor screening area.

LPA Marrufo observed the facility kitchen and observed a perishable food supply of at least 3 days and a non-perishable food supply of at least 7 days. LPA Marrufo observed a PPE supply of at least 30 days.

LPA Marrufo toured the outside area and observed the exits to be clear of obstructions.

No deficiencies were cited at this time as per California Code of Regulations Title 22.

This report was reviewed with Merlita Bathan and a copy of the report was provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2022
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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