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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202761
Report Date: 10/19/2022
Date Signed: 10/19/2022 04:50:25 PM

Document Has Been Signed on 10/19/2022 04:50 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: 2DATE:
10/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Xiuyan ChenTIME COMPLETED:
10:13 AM
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Licensing Program Analyst (LPAs) Steve Chang and Simi Rai conducted an unannounced inspection visit and met with Administrator (ADM) Xiuyan Chen. LPA addressed the purpose of today's visit to ADM. Upon arrival, ADM took LPAs body temperature, and checked LPAs in the visitor log book.

LPAs interviewed ADM. Two clients were observed in facility.

LPAs toured the facility inside out with ADM. Screening station with masks, hand sanitizer, glove, thermometer and visitor log book was observed at the main entrance. Living room, kitchen, dinning room and two restrooms were inspected. All trash cans were observed with covers. Paper towels were observed with holders. Cloth towels were observed in the kitchen and restrooms. Three resident bedrooms, and laundry room were inspected. Two ADM's private use bedrooms were observed outside the facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, were observed locked. Cleaning product closet were observed not locked. ADM stated ADM will put the lock on the cleaning product closet. Hot water temperature was at 108 degree F in facility.

Fire extinguisher was serviced on 09/16/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

ADM stated all the residents and staff are fully vaccinated. ADM will send the Infection Control Plan to LPAs.

No citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2022
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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