435202761-5-30-2025-26-AS-KHOS-DHPKY2-20250616081826

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202761
Report Date: 04/25/2025
Date Signed: 05/30/2025 04:53:02 PM

Unsubstantiated

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
02/24/2025 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20250224120330

FACILITY NAME:	ARF SWEET CARE HOME		FACILITY NUMBER:	435202761
ADMINISTRATOR:	CHEN, XIUYAN		FACILITY TYPE:	735
ADDRESS:	3283 MOUNT EVEREST DR		TELEPHONE:	(408) 649-3526
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95127
CAPACITY:	6	CENSUS: 2	DATE:	04/25/2025
		UNANNOUNCED	TIME BEGAN:	02:27 PM
MET WITH:	Xiuyan Chen		TIME COMPLETED:	03:17 PM

ALLEGATION(S):

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Staff did not dispense medication to resident as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation finding and met with Administrator (ADM) Xiuyan Chen.

On 2/24/2025, the Department received a complaint regarding staff did not dispense medication to resident as prescribed.

On 3/6/2025, the Department conducted an initial investigation visit.

LPA interviewed Administrator, a staff (S1), and 2 residents (R1, R2). LPA obtained resident physician reports, appraisal needs and service plans, central stored medication forms and Medication Administration Records (MAR).

Continue on LIC9099-C. Page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025

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-20250224120330

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: 04/25/2025

NARRATIVE

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Staff did not dispense medication to resident as prescribed:
On 3/6/2025, LPA interviewed Administrator Xiuyan Chen (ADM). ADM stated the facility administers medications to resident R1 based on doctor's prescriptions. ADM stated resident R1 sometimes went back to R1's family and the facility gave R1 his/her prescribed medication with him/her when R1 went back to his/her family house. ADM stated sometimes R1 brought some of his/her prescribed medications back when R1 returned to the facility.

LPA interviewed staff S1. S1 stated he/she administers R1's prescription medications to R1 based on doctor's prescription. S1 stated R1 sometimes went to his/her family house on weekends. S1 stated he/she gave R1's prescription medications to R1 for his/her visit at his/her family. S1 stated sometimes R1 brought back some of his/her prescription medications when he/she returned to the facility. S1 stated he/she asked ADM how to handle the medications returned to the facility by R1. S1 stated he/she received the instruction from ADM was "don't waste medications". S1 stated he/she administered the medications returned by R1 to R1 as usual as when R1 stays at facility. S1 stated he/she popped out the medication from pop package at the date he/she administered to R1. S1 stated he/she knows there was some mismatch because R1 returned some medications. S1 stated for a new month, R1's medication and document will be matched.

LPA interviewed resident R1. R1 stated the facility staff administer his/her prescribed medications to him/her on time every day when he/she is in the facility. R1 stated facility staff gave him/her medications when he/she visited his/her family. LPA asked if R1 always took his/her prescribed medications without missing when he/she visited his/her family. R1 did not answer. LPA asked if R1 took his/her prescribed medication back to the facility when he/she returned from his/her family. R1 stated Yes.

Based on the review of R1's Medication Administration Record, R1's prescribed medication were administered to R1. R1's prescription medications and centrally stored medication form are not matched due to R1 visited his/her family.

Based on interview, and records reviewed , the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.
No citations noted at today’s visit. The report was provided to ADM for review and signature. Page 2 of 2.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025

LIC9099 (FAS) - (06/04)

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