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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202761
Report Date: 10/30/2024
Date Signed: 10/31/2024 08:06:12 AM

Document Has Been Signed on 10/31/2024 08:06 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: 3DATE:
10/30/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Xiuyan ChenTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
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On 10/20/2024 at 10:15 a.m. Licensing Program Analysts (LPAs) Steve Chang and Mita Partoza, conducted an unannounced Case Management for Legal/Non-compliance inspection visit and was greeted by staff (S1) Jacqueline Morales. Administrator Xiuyan Chen was not present at the time LPAs arrival. S1 stated that there are 3 residents and 1 staff currently at the facility. ADM arrived at the facility at 10:30 a.m.

The purpose of the visit is to ensure that the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) as agreed upon during the Non-Compliance meeting on 3/28/2023. Case management for Legal/Non-Compliance will be conducted every 3 months for 2 years.

LPAs toured the facility inside and outside and found such as the kitchen, dining, living room, residents rooms, storage room, garage and exterior perimeters. LPAs observed the facility to be sanitary and maintained. Residents room have sufficient storage, bathrooms are equipped with grab bars and non-skid mats. The Facility temperature measured at 70 degree Fahrenheit. The water temperature measured at 105.1 degree Fahrenheit. LPAs observed knives, sharps and medications are locked and not accessible to residents. LPAs observed 2 days of perishable food and 7 days non-perishable food.

The facility was maintained and kept organized. The facility cleaning supplies and chemicals were kept in a separate storage that is locked and not accessible to resident. LPAs reviewed the 3 residents records such as but not limited to Admission Agreement, Centrally Stored Medication and Destruction Record (CSMDR), Physician's report, Appraisal Needs and Services Plan, Personal Rights, and Consent forms. LPAs reviewed 1 staff record and observed record to be complete and updated.

No deficiencies were cited during today visit. An exit interview was conducted with administrator/licensee Xiuyan Chen. A copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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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