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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202811
Report Date: 05/22/2025
Date Signed: 05/22/2025 02:06:05 PM

Document Has Been Signed on 05/22/2025 02:06 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SWEET CARE HOME IN GILROYFACILITY NUMBER:
435202811
ADMINISTRATOR/
DIRECTOR:		YALUNG, ELAINEFACILITY TYPE:
740
ADDRESS:318 CHURCHILL PLACETELEPHONE:
(510) 458-7231
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 5DATE:
05/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:10 PM
MET WITH:Emilyn SampanaTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct the facility's annual required - 1 year inspection. LPA met with lead staff, Emilyn Sampana.

During visit, LPA toured the facility with staff to include the kitchen, living room, dining room, resident bedrooms, staff bedroom, bathrooms, and backyard. All exit routes are free and clear of obstruction. The shed in the backyard contains storage items. All staff present are fingerprint cleared and associated to the facility. Residents observed watching a movie in the living room and one resident was asleep in bed.

Facility temperature maintained at 72 degrees Fahrenheit. Fire extinguisher last serviced on 08/15/2024. Facility has a smoke detector and carbon monoxide detector. Sharp objects, chemicals, and disinfectants observed secured in the kitchen. Chemicals and disinfectants stored separately from food supply. Medications observed in a locked cabinet. Facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator temperature maintained at 38 degrees Fahrenheit. Freezer temperature maintained at 0 degrees Fahrenheit. All items inside the refrigerator observed covered and labeled. The non-perishable foods are accessible and no child lock device observed on the cabinets.

Resident bedrooms equipped with hospital beds, linens, adequate lighting, chair, and dresser. Bathroom equipped with shower chairs and grab bars. Hot water temperature in the resident bathroom maintained at 114.4 degrees Fahrenheit. SEE LIC809-C.
NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: SWEET CARE HOME IN GILROY
FACILITY NUMBER: 435202811
VISIT DATE: 05/22/2025
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LPA reviewed 5 resident files. 5 out of 5 resident files observed complete and up-to-date. 5 out of 5 residents centrally stored medications and centrally stored medication records were reviewed and all medications were accounted for.

LPA reviewed 3 staff files. 3 out of 3 staff has an updated 1st aid certification, health screening report, and TB result. 3 out of 3 staff are fingerprint cleared and associated to the facility. 3 out of 3 staff are provided at least 20 hours of annual training per Title 22 regulations.

Facility has an emergency disaster plan. LPA advised Administrator to review the emergency disaster plan annually to ensure accuracy. Emergency drill was last conducted in January and April 2025. Facility has an infection control plan. LPA advised Administrator to review the infection control plan annually to ensure accuracy.

LPA observed the facility has a complete 1st aid kit and extra flash lights in case of an emergency.

Facility has PPE (Personal Protective Equipment) to include masks, gloves, and hand sanitizer which were observed throughout the facility.

No deficiencies were cited per California Code of Regulations, Title 22.

This report was reviewed with lead staff, Emilyn Sampana and a copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC809 (FAS) - (06/04)
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