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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202761
Report Date: 09/24/2024
Date Signed: 09/25/2024 07:59:19 AM

Document Has Been Signed on 09/25/2024 07:59 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
CENTRAL COAST CR/RES, 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: 4DATE:
09/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Xiuyan ChenTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit and met with Administrator/Licensee (ADM) Xiuyan Chen. LPAs observed 4 residents and 1 staff in the facility. LPA reviewed 2 resident files and 2 staff files.

LPA toured the facility inside and out with ADM. License and valid Administrator Certificate were observed at the main entrance. LPA did not observe personal rights posters posted in the facility. LPA toured living room, kitchen, dining area, restrooms, laundry area. The facility has 3 bedrooms and 2 restrooms. An office was observed in the garage. Medication closet, knives closet, and cleaning product closet were observed locked. Non-skid mat was not observed in one of the two restrooms. ADM bought a new non-skid mat and put in the restroom before LPA finished the inspection. Room temperature was observed at 80 degree F, and hot water temperature was observed at 119 degree F. Refrigerator temperature was measured at 37 degree F, and freezer temperature was measured at 0 degree F. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient.

The facility is equipped with fire alarm and smoke and carbon monoxide detectors. ADM tested the smoke and carbon monoxide detectors, and they were working fine. The fire extinguishers were observed on service on 9/19/2023. ADM asked the fire extinguisher service company to send staff to service on site before LPA finished the inspection. LPA inspected the backyard, there was no obstruction to block the walkway. Two storage rooms and one restroom were observed in the backyard. No obstruction blocked the walkway to the exit gate. First aid box was observed in the facility. LPA did not see flash lights and night light in the facility. ADM bought flash lights and night lights before LPA finished the inspection. The last time the facility conducted fire drill was on 4/24/2024.

Deficiencies noted today. See LIC809-D. Exit interview was conducted with ADM. The report was provided to ADM for signature. A copy of the reports were provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 09/25/2024 07:59 AM - It Cannot Be Edited


Created By: Chihhsien Chang On 09/24/2024 at 12:34 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: ARF SWEET CARE HOME
FACILITY NUMBER: 435202761

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that 1 out of 2 staff files were observed without health screening form which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2024
Plan of Correction
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ADM stated to submit a plan of correction by the POC due date to ensure staff have health screen forms maintained in the staff files.
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that 2 out of 2 staff files was observed without first aid certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2024
Plan of Correction
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ADM stated to submit a plan of correction by the POC due date to ensure staff have first-aid certificate maintained in the staff files.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024


LIC809 (FAS) - (06/04)
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