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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202761
Report Date: 05/15/2024
Date Signed: 05/16/2024 08:00:52 AM

Document Has Been Signed on 05/16/2024 08:00 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
CCLD Regional Office, 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) 946-8918
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 3DATE:
05/15/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Xiuyan ChenTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Steve Chang and Manuel Monter conducted an unannounced case management visit and met with administrator (ADM) Xiuyan Chen. LPAs observed 3 residents and 1 staff in the facility.

Based on record review of the facility file, ADM’s ARF Administrator's Certificate expired on 04/18/2024. There was no valid copy of ADM’s ARF Administrator’s Certificate found on the facility, nor ADM submitted a copy to CCL.

During today’s inspection visit, ADM stated that she completed the required training for the ARF Administrator’s Certificate herein it was submitted to CCLD Certification Unit on 03/27/2024. LPAs requested copies of completed required training to ADM, but she was unable to provide the evidence of training and hours completed. ADM’s name on the CCLD pending list of ADM renewals, is not on the list as of 5/15/24.

LPAs observed only 1 staff (S1) during visit. LPA verified S1 has a current fingerprint clearance, but he/she is not associated to the facility through Guardian and/or LIS. S1 stated began his/her employment since April 7, 2024. S1 works Tuesday -Saturday, as a live in staff. ADM admitted that she did not associate S1 to the facility personnel roster. As a result, deficiency is being cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty is being assessed for $500 ($100 per day x 5 days = $500) for S1 working in the facility without association.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
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 4
Document Has Been Signed on 05/16/2024 08:00 AM - It Cannot Be Edited


Created By: Chihhsien Chang On 05/15/2024 at 01:10 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: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/16/2024
Section Cited
CCR
85064(b)

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85064 Administrator Qualifications and Duties. (b) All adult residential facilities shall have a certified administrator.

This requirement was not met evidenced by:
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Administrator stated she will submit a written plan of correction on how she will ensure the facility has an administrator with an acitve ARF Administrators Certificate.
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Based on the interview, ADM’s ARF Administrator Certificate expired on 4/18/2024. ADM did not renew her ARF Administrator’s certificate in a timely manner herein there is no current ADM of the facility. ADM submitted her renewal 22 calendar days before the expiration date of April 18, 2024. ADM did not provide evidence of renewal for review in the facility.”
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Type A
05/16/2024
Section Cited
CCR80019(e)(3)

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80019 Criminal Record Clearance. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:(3) Request a transfer of a criminal record clearance as specified in Section 80019(f)
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ADM stated she will associate S1. ADM stated she will send a written plan of action on how she will ensure all staff are associated to the facility.
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Based on record review and interview, staff S1 began his/her employment since April 7, 2024. S1 is currently not associated with the facility personnel summary. ADM admitted S1 is not associated to the facility personnel summary.
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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: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/16/2024 08:00 AM - It Cannot Be Edited


Created By: Chihhsien Chang On 05/15/2024 at 02:27 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: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/22/2024
Section Cited
CCR
80026(h)

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80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents (h) Each licensee shall maintain accurate records of ...personal property, and valuables entrusted to his/her care...
This Requirement has not been met as evidenced by;
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ADM stated she will create a personal property log for R1-R3 and send a copy to LPA. ADM stated she will send a hand written letter of understanding regarding the regulation.
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Based on record review, residents R1-R3 do not have a personal property log. ADM stated she has not completed them yet and acknowledged she needs to complete them.
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ADM stated she will send the Plan of Corrections by May 22, 2024.
Type B
05/22/2024
Section Cited
CCR85068.2(b)

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85068.2 Needs and Services Plan (b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include
This requirement has not been met as evidenced by;
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ADM stated she will send a copy of a completed and signed needs and services plan for R1 and R2 to LPA. ADM stated she will also send a letter of understanding regading the regulation.
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Based on record review, residents R1 and R2 do not have needs and services plans. ADM stated she has not completed them and acknowleged she needs to complete them.
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ADM stated she will send the Plan of Corrections by May 22, 2024.
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: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 05/15/2024
NARRATIVE
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LPA's reviewed 3 Out of 3 resident files. R1 and R2's resident files did not have Needs and Services Plan. LPA's asked ADM if she had the forms, ADM stated she has not completed them yet but acknowledged she needs to complete them. R1-R3 does not have personal property log. LPA asked if the ADM had a personal property log. ADM stated she has not completed them yet but acknowledged she needs to complete them.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500) for S1 working in the facility without association.

LPA conducted an exit interview with ADM. A copy of this report was provided to ADM including Appeal rights.

Page 2 Out of 2.

END OF REPORT.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4