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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202761
Report Date: 09/25/2024
Date Signed: 09/26/2024 01:34:16 PM

Document Has Been Signed on 09/26/2024 01:34 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
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: 3DATE:
09/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:12 PM
MET WITH:Xiuyan ChenTIME VISIT/
INSPECTION COMPLETED:
05:53 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management - incident visit and met with Administrator (ADM) Xiuyan Chen.

Resident R1 moved in the facility on 9//20/2024.

On 9/24/2024, resident R1 left the facility without notice. Staff S1 tried to redirect R1 back to the facility but R1 did not want to return back to the facility. ADM called police department to report missing resident and asked police department to help to find R1.

On 9/25/2024, LPA interviewed staff S1. S1 stated he/she was cooking in the kitchen and did not notice R1 was going to leave the facility. S1 stated he/she found R1 left the main entrance door when he/she heard the sound of the main entrance door closed. S1 stated he/she followed R1 and tried to get R1 back to the facility but R1 kept walking to the bus stop. S1 stated R1 brought luggage with himself/herself. S1 stated he/she returned to the facility to check if R1 took all his/her belongings. S1 stated R1 took all his/her belongings with himself/herself. S1 stated he/she called ADM immediately.

LPA interviewed ADM. ADM stated he/she came back to the facility after S1 called him/her and checked the bus stop and neighborhood. ADM stated he/she cannot find R1 and he/she called police department to report missing resident and asked police department to help to find R1. ADM stated the police officers told him/her if they find R1 and R1 wants to return to the facility, then they will send R1 back to the facility. If R1 does not want to return back to the facility then they won't send R1 back to the facility.

Continue on LIC809-C. Page 1 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/25/2024
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ADM stated he/she talked to R1's case manager (CM) this morning, CM stated R1 called him/her and stated that R1 wants to stop the housing program with the company Telecare. ADM stated he/she did not receive any update from police department about R1's status.

LPA requested R1's physician report and appraisal needs and service plan.

Based on the review of R1's physician report, R1 is able to leave facility unassisted.

Based on the review of R1s appraisal needs and service plan, it specifies that R1 is a independent client.

The case management needs further investigation.

Exit interview was conducted with ADM. The 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: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2