435202761-7-29-2025-26-AS-SRAI-DK2MD6-20250729093037

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202761
Report Date: 07/29/2025
Date Signed: 07/29/2025 09:30:40 AM

Document Has Been Signed on 07/29/2025 09:30 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 HOME		FACILITY NUMBER:	435202761
ADMINISTRATOR/ DIRECTOR:	CHEN, XIUYAN		FACILITY TYPE:	735
ADDRESS:	3283 MOUNT EVEREST DR		TELEPHONE:	(408) 649-3526
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95127
CAPACITY: 6		CENSUS: 4	DATE:	07/29/2025
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:45 AM
MET WITH:	Licensee/Administrator Xiuyan Chen		TIME VISIT/ INSPECTION COMPLETED:	09:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Case Management for Legal/Non-compliance inspection visit. LPA Rai met with Licensee/Administrator Xiuyan Chen and stated the purpose of today's visit. LPA observed 4 residents and 2 staff (including Administrator) at the facility. 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 3/28/2023. LPA reviewed facility files pertaining to the Corrective Action Training Plan created in response to the Non-Compliance Conference. LPA observed the facility to include kitchen, dining room, living room and exterior perimeters. Knives, medications and chemicals were observed locked. Supplies of drinking water, two days perishable food supplies and seven days nonperishable food supplies were observed sufficient. No chemical were observed in the cabinet with food supplies. 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. LPA Rai reviewed the 2 residents records to include but not limited to Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, Centrally Stored Medication Record and Personal Rights. LPA Rai reviewed 1 staff record and observed record to be complete and updated. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensee/Administrator Xiuyan Chen and a copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Simranjit Rai
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/29/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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