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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202761
Report Date: 03/05/2023
Date Signed: 03/07/2023 12:14:12 PM

Document Has Been Signed on 03/07/2023 12:14 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: 5DATE:
03/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Xiuyen ChenTIME COMPLETED:
12:55 PM
NARRATIVE
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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.

S1 stated she works from 7:00AM - 7:00PM today to provide care and supervision to residents. LPAs toured the facility inside an out with S1. 2 day perishable food supplies and 7 days nonperishable food supplies were observed to be sufficient. Detergent closet, medication closet and knives closet were observed locked.

S1 tested the facility alarm system, and it worked fine. LPAs toured 2 restrooms and 3 bedrooms. 5 residents were observed in facility. S1 does not have the key for the 2 extra rooms to open for LPAs to inspect.

ADM showed the Administrator Certificate to LPAs. The certificate will expire in April 2023. LPAs suggested ADM to renew immediately.

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: 03/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2023
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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