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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202761
Report Date: 07/12/2024
Date Signed: 07/12/2024 05:04:34 PM

Document Has Been Signed on 07/12/2024 05:04 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:ARF SWEET CARE HOMEFACILITY NUMBER:
435202761
ADMINISTRATOR/
DIRECTOR:		CHEN, XIUYANFACILITY TYPE:
735
ADDRESS:3283 MOUNT EVEREST DRTELEPHONE:
(408) 649-3526
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 3DATE:
07/12/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Xiuyan ChenTIME VISIT/
INSPECTION COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Steve Chang and Manuel Monter conducted an unannounced Case Management Legal/Non-compliance inspection visit and met with Administrator/Licensee (ADM) Xiuyan Chen. LPAs observed 3 residents and 1 staff in the facility. LPAs addressed the purpose of the visit to ADM.

On 07/03/2024, the Department informed ADM/Licensee (by phone) about the accusation. ADM/Licensee confirmed receipt of the of the Accusation for ARF Sweet Care Home on July 8, 2024. #435202761 and Senior Sweet Care Home #435202858 (a closed facility). On 7/12/2024, ADM/Licensee posted a copy of the accusation in the prominent area in the facility. LPAs advised ADM/Licensee to review Health and Safety Code 1569.38 and to notify residents' families and Long-Term Care Ombudsman (LTCO) regarding the accusation. A copy of Health and Safety code 1569.38 was provided.

LPA also discussed ADM/Licensee's presence in the facility. ADM/licensee stated he/she reports in the facility Sunday-Friday, at least 4 hours per day. The facility was toured inside and out with ADM.

LPA requested an updated LIC500.

This visit report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2024
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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