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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202761
Report Date: 03/04/2023
Date Signed: 03/05/2023 09:00:44 AM

Document Has Been Signed on 03/05/2023 09:00 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:CHEN, XIUYANFACILITY TYPE:
735
ADDRESS:3283 MOUNT EVEREST DRTELEPHONE:
(408) 946-8918
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 5DATE:
03/04/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:18 PM
MET WITH:Xiuyen ChenTIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPAs) Steve Chang and Ryker Heberle conducted an unannounced Case Management - deficiency inspection visit, and met with staff Jisselle Penales (S1) and Administrator (ADM) Xiuyen Chen.

LPAs toured the facility inside an out with S1. Bleach was observed to be accessible in facility bathroom underneath the sink. LPAs also observed engine coolant and power steering fluid underneath the sink in additional bathroom. 2 facility rooms observed to have foul odor. Cleaning supplies observed to be stored in medication cabinet. ADM moved all cleaning supplies to spare room room away from facility medication. Medication closet and knives closet were observed locked. 2 days perishable food supplies and 7 day nonperishable food supplies were observed not sufficient. Gardening supplies observed available to residents. ADM stated she was in the process of leaving to go grocery shopping, but LPAs arrived as she was leaving. ADM stated she will go grocery shopping later. Fire extinguisher was serviced on 9/16/2022.

S1 stated she was sent by agency to provide care and supervision, and the working schedule is from 7:00AM - 7:00PM for today. LPAs observed S1 cooked and provided the food to residents.

LPAs wanted to access the extra 2 bedrooms, S1 stated she does not have the keys. ADM stated the residents in the 2 extra rooms moved out last night (3/3/2023). ADM opened one of the extra rooms for LPA, but ADM did not have the key for the other extra room since the previous resident did not return the key yet. ADM conformed both residents moved out already.

No citation noted during inspection. 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: 03/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2023
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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