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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202858
Report Date: 02/10/2022
Date Signed: 02/10/2022 04:23:03 PM

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:SENIOR SWEET CARE HOMEFACILITY NUMBER:
435202858
ADMINISTRATOR:CHOW, MADELINEFACILITY TYPE:
740
ADDRESS:251 DELIA STREETTELEPHONE:
(408) 649-3202
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:6CENSUS: 5DATE:
02/10/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Xiuyan ChenTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Steve Chang conducted a pre licensing inspection visit, and met with administrator (ADM) Xiuyan Chen. Upon arrival, ADM took LPA body temperature and checked LPA into the guest book. Screening station with thermometer, masks, hand sanitizer was observed at the main entrance. COVID posters were observed at the main entrance and in facility. 4 residents were observed in facility.

LPA toured the facility inside out with ADM. LPA inspected living room, family room, kitchen, dinning area, and laundry room. Medication closet, knives closet, and cleaning product closet were observed locked. There are 3 shared rooms for residents, and one staff live-in room in facility. 3 bathrooms were inspected. Not all paper towels were with holders, Cloth towels were observed in kitchen and restrooms. Some sinks were observed without washing hands signs by the sinks. ADM stated the facility will fix these issue in three days. ADM stated the facility will replace the resident file binders with the bigger binders. Room temperature was observed at 68 degree F, and hot water temperature was observed at 107 degree F.

The facility is equipped with smoke and carbon monoxide detectors. The facility equipped with fire alarm. ADM tested the smoke and carbon monoxide detectors, and they were working fine. The fire extinguishers were observed on service on 09/30/2021. LPA inspected the backyard, there was no obstruction to block the walkway.

LPA discussed LIC808 mitigation plan with ADM. ADM stated all staff and residents are fully vaccinated. Component III orientation was conducted with ADM.

No deficiency or issue noted during inspection. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
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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