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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202761
Report Date: 03/07/2023
Date Signed: 03/08/2023 08:37:10 AM

Document Has Been Signed on 03/08/2023 08:37 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:
03/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:59 PM
MET WITH:Xiuyen Chen.TIME COMPLETED:
05:50 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) Xiuyen Chen and staff (S1).

LPAs interviewed staff (S1). S1 stated S1 was sent by an agency to work here from 10:00AM - 6:00PM for today.

LPAs toured the facility and backyard. S1 Opened one of the 2 extra rooms, but S1 did not have the key for the other one. of the 2 extra rooms was cleared, and no one lives inside. S1 stated he/she saw someone came in to move out some stuff from one of the 2 extra rooms.

ADM came in facility later after LPAs interviewed S1. ADM opened the 2 extra bedrooms for LPA to inspect. The 2 extra bedrooms are cleared, and no one lives in side. The 2 extra bedrooms are not part of the facility.

LPAs informed ADM to send the POCs on time. LPAs informed ADM to send the requests for extension of POC, if ADM cannot send the POCs by the deadline.

Exit interview was conducted with ADM. The repot was provided to ADM for signatures.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2023
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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