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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202858
Report Date: 10/17/2023
Date Signed: 10/17/2023 04:55:01 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/27/2023 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20230227111713
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:0CENSUS: 0DATE:
10/17/2023
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Xiuyan ChenTIME COMPLETED:
03:43 PM
ALLEGATION(S):
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Facility staff are not ensuring that a resident receives adequate care.
Facility staff are not ensuring that resident receives the right medication.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Steve Chang and Emanuel Monter conducted an unannounced Complaint Investigation visit to deliver investigation finding of the above allegations that staff are not ensuring that resident receives the right medication. Met with Administrator (ADM) Xiuyen Chen.

On March 7, 2023, an initial complaint investigation visit was conducted by interviewing the Administrator (ADM), two care staff (S1, S2), and 5 residents (R1 to R5). During the visit, the facility food supplies were observed.


Continue on LIC9099-C. Page 1 of 3
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 26-AS-20230227111713
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 435202858
VISIT DATE: 10/17/2023
NARRATIVE
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Facility staff are not ensuring that resident receives the right medication:
On March 7, 2023, LPA interviewed staff S1 and S2. Both staff stated the facility stored the medications for residents, and they were assigned to administer medications to residents according to residents’ MD prescription order(s).

The facility is utilizing Medication Administration Record (MAR). LPA conducted a review of the facility MAR wherein there were no initials of staff who assisted with the medication. Staff stated they do not initial MAR when administering/assisting with residents’ medication; the ADM initials it for them (staff). Moreover, staff denied that they administered wrong medications to residents.

On March 07, 2023, LPA interviewed Administrator (ADM). ADM denied there was a medication error occurred in the facility. ADM stated he/she administered medications to residents and documents on the resident's Medication Administration Record (MAR).

On March 07, 2023, LPA interviewed 5 residents (referred as R1 to R5). 5 Out of 5 residents stated the facility stored their medications and staff assisted them with their medications. They stated that staff has not administered them wrong medications.

A review of the facility’s Program Plan on Medication Procedures states “all resident medication must be documented AND kept current on the Centrally Stored Medications Records and Destruction Form LIC622.”
Based on the department’s review of the facility’s medication procedures which generally states staff are responsible for medication documentation.

Continue on LIC9099-C. Page 2 of 3.

SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/27/2023 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20230227111713

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:0CENSUS: DATE:
10/17/2023
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Xiuyan ChenTIME COMPLETED:
03:43 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff are not ensuring that a resident is adequately fed.
Facility does not have centrally stored medication log.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
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13
Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Complaint Investigation visit to deliver the investigation finding on the allegation that facility does not have centrally stored medication log. Met with Administrator (ADM) Xiuyan Chen.

On March 07 2023, an initial complaint investigation visit was conducted. LPA met and interviewed with the Administrator (ADM), two staff (S1, S2), and 5 residents (referred as R1 to R5).


Continue on LIC9099-C. Page 1 of 2.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 26-AS-20230227111713
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 435202858
VISIT DATE: 10/17/2023
NARRATIVE
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Facility does not have centrally stored medication log:

On March 07, 2023, LPA interviewed Administrator (ADM). ADM stated that residents’ medications are documented LIC 622 Centrally Stored Medication and Destruction Record. 5 Out of 5 residents (R1 to R5) have LIC 622 Centrally Stored Medication and Destruction Record were reviewed.

Facility staff are not ensuring that a resident is adequately fed:

On March 07, 2023, LPA interviewed Administrator (ADM). ADM stated that he/she does the grocery shopping only when he/she found food supplies were insufficient. ADM stated that he/she does not purchase large volume of food supplies at one time because he/she preferred serving fresh foods and cooked meals and provided snacks for residents.



2 Out of 2 staff (referred as S1 and S2) were interviewed wherein they stated the facility perishable food could only last for one or two days. On the other hand, they stated that the facility food supplies were never empty. 5 Out of 5 residents did not complain about the food quality and/or quantity served by the facility and states the facility provides 3 meals and snacks, and 3 out of 5 residents stated that facility food was "good" and "enough".

2 Out of 5 residents (who are referred as R3 and R5) were interviewed. R3 stated the facility food was good, but he/she prefers the food brought by his/her family member while R5 stated the facility food was good, but he/she likes to eat out at restaurants. While none of the other 3 residents complained about the quality and/or quantity of the facility foods.

Based on the interviews, the food supplies of one of the 5 residents were most from his/her family member and one of the 5 residents most of time ate at restaurants outside the facility.

The Department has investigated the above allegation. Based on the investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No citations cited under California Code of Regulations Title 22. Exit interview conducted with ADM. The report was provided to ADM for signature. A copy of the report was provided to ADM.
Page 2 of 2.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20230227111713
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 435202858
VISIT DATE: 10/17/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
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19
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acility staff are not ensuring that resident receives the right medication:
On March 7, 2023, LPA interviewed staff S1 and S2. Both staff stated the facility stored the medications for residents, and they were assigned to administer medications to residents according to residents’ MD prescription order(s).

The facility is utilizing Medication Administration Record (MAR). LPA conducted a review of the facility MAR wherein there were no initials of staff who assisted with the medication. Staff stated they do not initial MAR when administering/assisting with residents’ medication; the ADM initials it for them (staff). Moreover, staff denied that they administered wrong medications to residents.

On March 07, 2023, LPA interviewed Administrator (ADM). ADM denied there was medication a error occurred in the facility. ADM stated he/she administered medications to residents and documents on the resident's Medication Administration Record (MAR).

On March 07, 2023, LPA interviewed 5 residents (referred as R1 to R5). 5 Out of 5 residents stated the facility stored their medications and staff assisted them with their medications. They stated that staff has not administered them wrong medications.

A review of the facility’s Program Plan on Medication Procedures states “all resident medication must be documented AND kept current on the Centrally Stored Medications Records and Destruction Form LIC622.”
Based on the department’s review of the facility’s medication procedures which generally states staff are responsible for medication documentation.

The Department has investigated the above allegation. Based on documents reviewed and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.



No citations cited under California Code of Regulations Title 22. Exit interview conducted with ADM. The report was provided to ADM for signature. A copy of the report was provided to ADM.

Page 3 out of 3.

SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5