<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202761
Report Date: 06/29/2023
Date Signed: 06/29/2023 04:44:01 PM

Document Has Been Signed on 06/29/2023 04:44 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:CHEN, XIUYANFACILITY TYPE:
735
ADDRESS:3283 MOUNT EVEREST DRTELEPHONE:
(408) 946-8918
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 3DATE:
06/29/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Xiuyan Chen. TIME COMPLETED:
04:15 PM
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 Analysts (LPAs) Steve Chang and Simi Rai conducted an unannounced Case Management - Legal/Non-compliance inspection and met with Administrator (ADM) Xiuyan Chen.

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 03/28/23.

LPAs discussed with ADM regrading the plans of preventing lack of supervision and care on residents, ensuring staff are available 24 hours/ 7 days, updating Administrator Certificate, understanding of the personal rights, ensuring adequate staff necessary for residents' care and supervision, and updating facility's emergency plan. LPAs discussed with ADM for updating facility policies and procedures of the standards for the facility operations. LPAs discussed with ADM to maintain resident files and staff files.

LPAs toured the facility inside and out with ADM and checked/inspected for the storage of disinfectants, two extra storage rooms, restrooms and resident bedrooms, and the garage. LPA checked the facility LIC 500 and the Administrator Certificate. Two days perishable food supplies and seven days non perishable food supplies were observed sufficient.

LPAs discussed with ADM regarding providing staff training with observation and assessment of residents, personal rights, and mandatory reporting. LPA obtained documents regarding the facility's written plan to address the prior deficiencies.

See Page 2 of 2, continuation page 809-C.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2023
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 3
Document Has Been Signed on 06/29/2023 04:44 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 06/29/2023 at 03:12 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: 06/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/30/2023
Section Cited
CCR
85087(a)(3)

1
2
3
4
5
6
7
85087 Buildings and Grounds(a)(3) No room commonly used for other purposes shall be used as a bedroom for any person.

This requirement is not met by:
1
2
3
4
5
6
7
Licensee will shift S1 to Resident Bedroom #3 and will re-submit facility sketch with Resident Bedroom #3 changed to Staff Room. Licensee will submit written plan understanding regulation by POC date
8
9
10
11
12
13
14
Based on observation and interview, Licensee set up staff room in the living room and S1 is using it as bedroom which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
8
9
10
11
12
13
14
Type A
06/30/2023
Section Cited
CCR80087(g)(1)

1
2
3
4
5
6
7
80087 Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons... & other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients (1) Storage area for... other dangerous weapons shall be locked.
This requirement is not met by:
1
2
3
4
5
6
7
Licensee removed observed items and placed them in a locked area during today's visit. Licensee will submit a signed written plan understanding of this regulation and how the facility will comply with regulation. Licensee will submit picture of locked cabinet in kitchen by POC date.
8
9
10
11
12
13
14
Based on inspection, LPAs observed antibacterial hand wipes, ajax cleaning solution, dishwashing soap & other cleaning solutions including unlocked drawer in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
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: 06/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 435202761
VISIT DATE: 06/29/2023
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
26
27
28
29
30
31
32
LPAs observed a sleeping area in the living room for staff which was not specified in the sketch map. ADM stated S1 is live-in staff and uses the area as a bedroom. LPAs observed antibacterial hand wipes, ajax cleaning solution, dishwashing soap & other cleaning solutions including unlocked drawer in the kitchen. ADM removed the items and placed in the locked medication closet.

Based on the documents reviewed, observation and interviewed conducted, the facility is not in compliance.

Deficiencies were cited from California Code of Regulations, Title 22 during today's visit, see 809-D.

A civil penalty is being assessed for the amount of $250 for facility storing disinfectants and cleaning solutions in unlocked cabinet in the kitchen. Please see LIC 421FC.

Exit interview was conducted with Administrator Xiuyan Chen. LIC809-D was attached. Appeal Rights was provided. The report was provided to Administrator Xiuyan Chen for signature. A copy of the report was provided to Administrator Xiuyan Chen.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3