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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202761
Report Date: 03/03/2023
Date Signed: 03/08/2023 08:41:37 AM

Document Has Been Signed on 03/08/2023 08:41 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:CHEN, XIUYANFACILITY TYPE:
735
ADDRESS:3283 MOUNT EVEREST DRTELEPHONE:
(408) 946-8918
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 5DATE:
03/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:21 PM
MET WITH:Licensee/Administrator Xiuyan CHenTIME COMPLETED:
06:45 PM
NARRATIVE
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Licensing Program Manager (LPM) Romeo Manzano and Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit. LPM and LPA met with Licensee/Administrator Xiuyan Chen.

Upon arrival, temporary agency caregiver (S1) opened the door and introduced themselves to LPM and LPA. Licensee/Administrator Xiuyan Chen was not present at the time. LPA Rai called Licensee at 4:24pm. Licensee arrived at the facility at 4:49pm. LPM and LPA toured the facility, interior and exterior and spoke to the residents at the facility. Licensee has hired one contracted temporary agency staff to be at the facility from 7am to 7pm until March 10th, 2023. Licensee will stay at the facility from 7pm to 7am.Licensee will submit LIC 500 Personnel Report to the Department by tomorrow March 4th, 2023 before midnight.

LPM and LPA delivered LIC 809-D from previous visit 3/2/2023. During the visit 3/2/2023, there was a technical difficulty with the printer and could not print out LIC 809 and LIC 809-C. The document was converted into a PDF and email to the Licensee directly. During this process, the incomplete LIC 809-D was final printed as well. All documents needed to be amended to finalize the LIC 809-D to be presented during today's visit.

There was one typo in the LIC 809-D on page 5 for a type B deficiency the Plan of Correction is 3/6/2023, not 3/3/2023. Licensee verbally understood about the new Plan of Correction date.
All Type A deficiencies are due 24 hours before midnight on Friday, March 3rd, 2023. All Type B deficiencies are due midnight on Monday, March 6th, 2023. LPM and LPA reminded Licensee to review all deficiencies and notify the Department for an extension and provide a valid reason and new date of extension.
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This report was reviewed with Administrator/Licensee Xiuyan Chen. A copy of the report and Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2023
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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