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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294286
Report Date: 09/28/2024
Date Signed: 09/28/2024 11:05:04 AM

Document Has Been Signed on 09/28/2024 11:05 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:WILLIE CARE HOME IIFACILITY NUMBER:
435294286
ADMINISTRATOR/
DIRECTOR:		ZHAO, WUSHENGFACILITY TYPE:
740
ADDRESS:1136 SOUTH MARY AVENUETELEPHONE:
(408) 749-8758
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY: 6CENSUS: 6DATE:
09/28/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Administrator, Guili "Penny" XuTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation and clear the deficiencies issued during today's visit. LPA Rai met with the Administrator, Guili "Penny" Xu and stated the purpose of today’s visit.

During today's visit, LPA Rai cleared two deficiencies issued during today's visit. During the investigation, Licensee provided a written plan of action to ensure medications and toxic chemicals such as a laundry detergents and disinfecting wipes were stored inaccessible to residents in care.

During today's visit, LPA observed the medications and toxic chemicals such as a laundry detergents and disinfecting wipes were stored inaccessible to residents in care.

LPA Rai provided Licensee Letter of Deficiency Citations Cleared for deficiencies issued during today's visit.

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
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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