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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202761
Report Date: 03/02/2023
Date Signed: 03/08/2023 08:44:50 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
03/01/2023 and conducted by Evaluator Simranjit Rai
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20230301170446
FACILITY NAME:ARF SWEET CARE HOMEFACILITY NUMBER:
435202761
ADMINISTRATOR:CHEN, XIUYANFACILITY TYPE:
735
ADDRESS:3283 MOUNT EVEREST DRTELEPHONE:
(408) 946-8918
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:6CENSUS: 5DATE:
03/02/2023
UNANNOUNCEDTIME BEGAN:
10:41 AM
MET WITH:Adminstrator/Licensee Xiuyan ChenTIME COMPLETED:
09:00 PM
ALLEGATION(S):
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Residents are left alone without staff supervision
INVESTIGATION FINDINGS:
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Licensing Program Manager (LPM) Romeo Manzano and Licensing Program Analyst (LPA) Simi Rai conducted an unannounced investigation visit and met with Administrator (ADM)/ Licensee Xiuyan Chen. LPM and LPA addressed the purpose of today's visit.

LPM and LPA arrived at the facility at 10:41am. Upon arrival, LPM and LPA met a case manager (CM-1) for a resident (R1) who also confirmed there were not staff present at the facility during C-1’s visit.

LPM and LPA interviewed R1-R4. 4 out of 4 residents stated the Licensee comes to the facility to prepare and cook meals 3 times a day and assist with residents’ medications but leaves the residents unsupervised in between meals and after 6 - 6:30pm. ADM stated that ADM comes in the facility between 8am/830am but sometimes at 7am. ADM left the facility last night at 630pm, 03/1/2023.

Please review LIC 9099-C for further investigation findings.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
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 4
Control Number 26-AS-20230301170446
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: ARF SWEET CARE HOME
FACILITY NUMBER: 435202761
VISIT DATE: 03/02/2023
NARRATIVE
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Based on interviews with 5 residents (R1 to R4), staff are not present at the facility 24 hours, 7 days a week. ADM stops by the facility to cook fresh meals three times a day and leaves after food and medications are served.

ADM/Licensee reported to the facility at 8:15am today and left the facility 9:45am after breakfast. ADM arrived at the facility at 11:45am once LPA Rai called Licensee at 11:15am

During visit, LPM and LPA had to supervise residents while ADM had to leave the facility twice at 1:40PM to pick up ADM’s computer and returned at the facility at 2PM and ADM left at 4:30pm and returned at around 5:30PM to assist with medications at ADM’s RCFE. ADM was the only staff associated at this facility.

LPM and LPA observed 5 residents at the facility and no staff members were present at the facility during visit. Licensee was not initially at facility but later came after all resident interviews were done.

Per ADM/Licensee, Tenant 1 (T-1) will pass medications on behalf of ADM and T1 lives on the facility without background fingerprint clearance or associated to the facility.

Per ADM/Licensee, S2 (husband) used to work at this facility and provide supervision while ADM is out of the facility to run errands such as shopping and supervising at ADM’s RCFE facility. ADM stated that S2 began S2’s employment, on and off, since licensure of the facility. ADM stated that S2 is no longer allowed to work as of 02/24/2023.

Based on LPAs’ observation, interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 26-AS-20230301170446
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: ARF SWEET CARE HOME
FACILITY NUMBER: 435202761
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/03/2023
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met by:
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Licensee ageed and understood residents needs to be provided care and supervision 24 hours, 7 days a week. Licensee to submit a written and signed statement for understanding of 80078 regulation and LIC 500 Personnel Summary by POC date.
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Based on observation and interviews, Licensee comes to the facility to prepare and cook meals 3 times a day and assist with residents’ medications but leaves the residents unsupervised in between meals and after 6 - 6:30pm returns back the following morning daily which is an immediate safety risk to the residents in care.
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Type A
03/03/2023
Section Cited
CCR
80065(a)
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80065 Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement is not met by:
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Licensee ageed and understood to follow the facility's Program Plan and regulations 80065 regarding hiring and retaining staff to provide care and supervision 24 hours a day, 7 days a week by POC date.
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Based on observation and interview, S1 was the only staff associated to this facility. S1 confirmed that S1 is the only staff. S1 leaves the facility afer serving breakfast between 7/8-9am then comes back for lunch at 1pm then leaves. S1 comes back to the faciltiy to cook for dinner between 6/630pm daily which is an immediate safety risk to the residents in care.
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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: 03/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 26-AS-20230301170446
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: ARF SWEET CARE HOME
FACILITY NUMBER: 435202761
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/03/2023
Section Cited
CCR
80072(a)(2)
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Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement is not met by:
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Licensee ageed and understood residents needs to be provided carea and supervision 24 hours, 7 days a week. Licensee to submit a written and signed statement for understanding of 80072 regulation by POC date.
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Based on overall outcome of today's inspection/investigation, the licensee did not provide a safe, healthful and comfortable accommodation such as but not limited to leaving residents unassisted, allowing non-fingerprinted individuals, unlocked toxic/hazardous materials, inadequate food supplies including water, and medications administration which is an immediate safety risk to the residents in care.
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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: 03/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4