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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202761
Report Date: 09/29/2023
Date Signed: 10/02/2023 07:55:45 AM


Document Has Been Signed on 10/02/2023 07:55 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: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: 3DATE:
09/29/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Xiuyan ChenTIME COMPLETED:
04:16 PM
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Licensing Program Analysts (LPAs) Steve Chang and Mita Partoza conducted an unannounced Case Management - Legal/Non-compliance inspection and met with Administrator (ADM) Xiuyan Chen.

The purpose of the visit is to ensure that facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after a Non-Compliance Conference held on 03/28/23. The case management of inspections will be conducted every 3 months for 2 years.

LPAs checked the Garage and found the garage was empty. LPAs checked the two extra rooms at the backyard, and both rooms were used as storage room. Knives closet, medications closet and detergent closet under the sink in kitchen were observed locked. LPAs checked the facility food supplies with ADM. Two days perishable food supplies and seven days nonperishable food supplies were observed sufficient. LPA checked residents' physician reports, Appraisal Needs and Service Plans and Centrally stored medications log, and they are up to date.

LPAs discussed with ADM regarding providing staff training and check staff training log. LPAs discussed with ADM regarding residents' personal rights, and mandatory reporting.

LPAs observed a sleeping partition in the living room measured as 8"L X 5"D X 6"H which staff rest/sleep inside. LPAs will contact San Jose CIty Planning Division Department to determine if permit is needed. ADM moved the staff to an empty bedroom from the sleeping partition temporarily. Based on observation and occurrence of communication between agency, citation is pending for the sleeping room built inside the living room area and is dependent on the determination of City Code Department.

Exit interview was conducted with ADM. The report was provided to ADM for signature. A copy of the report was provided to ADM
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023
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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