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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294286
Report Date: 04/30/2025
Date Signed: 04/30/2025 01:51:13 PM

Document Has Been Signed on 04/30/2025 01:51 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
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: 5DATE:
04/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Guili XuTIME VISIT/
INSPECTION COMPLETED:
02:05 PM
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On April 30, 2025, at 08:45 AM, the Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. The LPA met with the Administrator, Guili Xu, and disclosed the purpose of the inspection. The Administrator informed the LPA that the facility had five (5) residents in care and two (2) staff members present at the time.

At 9:17 AM, the LPA initiated a walk-through of the facility, accompanied by the Administrator. The indoor temperature reading of 72°F on a thermostat was observed in the hallway at the time of the visit.

LPA inspected the kitchen and observed breakfast preparation and cooking in progress at the time. The appliances were checked and observed to be in working order. The LPA inspected a locked cabinet under the sink containing detergents, disinfectants, cleaning supplies, knives and sharp objects. The refrigerator and pantry cabinets were inspected, and sufficient supplies of fresh perishable food for (2) days and nonperishable staples for (7) days were observed. No expired food or stored medications were noted.

LPA inspected the dining area adjacent to the kitchen. The dining table and chairs were observed to accommodate the residents, and all the furniture was in good repair. LPA inspected the fire extinguisher mounted on the wall in the dining area and found it fully charged, with the last service tag dated 05/01/2024. LPA advised the Administrator to have the fire extinguisher serviced as soon as possible for the year 2025.

At 09:28 AM, LPA inspected the garage and observed the garage cluttered with incontinence supplies, furniture, food supplies, Christmas decorations, suitcases, several wooden doors, cabinets, wheelchairs, and mattresses.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2025
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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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)
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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: WILLIE CARE HOME II
FACILITY NUMBER: 435294286
VISIT DATE: 04/30/2025
NARRATIVE
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LPA inspected the laundry room next to the kitchen and observed a washer, a dryer there.

LPA inspected the living room and observed a sofa set, chairs, recliner, coffee table, covered fireplace, small refrigerator, music system, and a television. One (1) resident was observed sitting on the recliner and watching TV. Board games, chess, puzzles, arts, coloring, bingo, and other recreational activity items for residents’ activities were also observed in the living room.

The Administrator tested the smoke and carbon monoxide detector located in the living room in the LPA's presence, and it was found to be functional. Additional smoke and carbon monoxide detectors were observed in all bedrooms and common areas of the facility during the visit.

LPA toured the backyard area and found ramps and passageways in good condition, clear of obstructions, with no blocking or tripping hazards. The backyard had a set of a patio table, chairs, and umbrella for resident use. No accessible bodies of water were found. LPA inspected (1) storage shed and observed wheelchairs, walkers, and furniture items in the shed.

There were six (6) bedrooms and four (4) bathrooms designated for residents' use. All (6) resident rooms were single occupancy. LPA inspected all (6) resident rooms and found them clean, well-lit, and equipped with the required furniture. Storage closets with incontinence supplies were observed in the rooms. LPA inspected four (4) full bathrooms and found them in good working condition. The bathrooms contained soap, grab bars, paper towels, a trash can, a shower bench, and non-slip mats/flooring. At 9:46 AM, the hot water temperature at the sink faucet measured 127.8°F in bathroom #1, 126.2°F in bathroom #2, and 127.8°F in bathroom #4.

At 09:43 AM, the LPA inspected the storage space in the hallway closet and observed it containing linens for residents’ use and found that sliding door was dangling and the door track was broken on the bottom.

LPA reviewed five (5) staff personnel records and five (5) resident records. At, 10:56 AM, The LPA observed that 4 of 5 residents did not have Safeguards for property/valuables inventory filed, dated, and signed. 1 of 5 residents had last annual Physician assessment done on 2/25/2021 and 2 of 5 residents’ assessment was done in the year 2023. LPA observed that 5 of 5 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 5 of 5 staff members were associated with the facility.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025
LIC809 (FAS) - (06/04)
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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: WILLIE CARE HOME II
FACILITY NUMBER: 435294286
VISIT DATE: 04/30/2025
NARRATIVE
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At 11:38 AM, the LPA observed a locked centrally stored medication cabinet located inside in the dining area next to the kitchen. Medications were organized in separate boxes for each resident. 5 of 5 resident’s medication prescription names, prescription numbers, and date filled were not entered correctly in the Centrally Stored Medication Records (CSMR). 5 of 5 resident’s prescription medication labels were altered with the handwritten notes on it.

LPA inspected the first aid kit and found it fully stocked.

LPA reviewed Emergency Drill Logs and observed Emergency Disaster Drills were conducted quarterly, with the most recent drill completed on 3/25/2025.

The following updated forms are requested to be submitted to CCLD by 05/07/2025:

  • LIC 500: Personnel Report
  • LIC 308: Designation of Facility Responsibility
  • Certificate of Liability Insurance
  • Administrator Certificate(s)

The deficiencies are being cited based on LPA observations, records reviewed, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.

An exit interview was conducted, and Plans of Correction were reviewed and developed with the Administrator. A copy of this report and appeal rights were discussed and provided to the Administrator, Penny Xu, whose signature on this form confirms receipt of these documents.

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Kiran Jain
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/30/2025 01:51 PM - It Cannot Be Edited


Created By: Kiran Jain On 04/30/2025 at 01:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 04/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.153(d)
Licensing
(d) A written resident personal property inventory is established upon admission and retained during the resident’s stay in the residential care facility for the elderly. Inventories shall be written in ink, witnessed by the facility and the resident or resident’s representative, and dated. A copy of the written inventory shall be provided to the resident or the person acting on the resident’s behalf. All additions to an inventory shall be made in ink, and shall be witnessed by the facility and the resident or resident’s representative, and dated. Subsequent items brought into or removed from the facility shall be added to or deleted from the personal property inventory by the facility at the written request of the resident, the resident’s family, a responsible party, or a person acting on behalf of a resident. The facility shall not be liable for items which have not been requested to be included in the inventory or for items which have been deleted from the inventory. A copy of a current inventory shall be made available upon request to the resident, responsible party, or other authorized representative. The resident, resident’s family, or a responsible party may list those items which are not subject to addition or deletion from the inventory, such as personal clothing or laundry, which are subject to frequent removal from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the Administrator did not ensure that for 4 of 5 resident’s safeguards for property/valuables inventory was filed, dated, and signed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2025
Plan of Correction
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The Administrator stated that they would complete the safeguards for property/valuables inventory with resident's or their family's signature and date. The Administrator will submit the evidence to CCLD by 05/07/2025.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Kiran Jain
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/30/2025 01:51 PM - It Cannot Be Edited


Created By: Kiran Jain On 04/30/2025 at 01:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 04/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the Administrator did not ensure garage was clean, organized, and not cluttered and the hallway cabinet sliding doors were dangling, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2025
Plan of Correction
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The Administrator stated that they would clean and organize the garage, and fix the hallway cabinet doors. The Administrator will submit the photographic evidence to CCLD by 05/07/2025.
Type B
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the Administrator did not ensure that for 5 of 5 resident’s prescription medication labels were not altered with the handwritten notes using a pen, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2025
Plan of Correction
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The Administrator will ensure not to write anything on the medication prescription labels and submit the proof of correction to CCLD by 05/07/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Kiran Jain
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/30/2025 01:51 PM - It Cannot Be Edited


Created By: Kiran Jain On 04/30/2025 at 01:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 04/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(6)(E)
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (E) The prescription number and the name of the issuing pharmacy.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the Administrator did not ensure that for 5 of 5 resident's medication prescription names, prescription numbers, and date filled were entered correctly in the Centrally Stored Medication Records, which poses/posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2025
Plan of Correction
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The Administrator will write correct prescription name, numbers, and date filled for each of resident's medications in Centrally Stored Medication Records and submit the proof of correction to CCLD by 05/01/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Kiran Jain
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2025


LIC809 (FAS) - (06/04)
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