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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202858
Report Date: 03/04/2023
Date Signed: 03/05/2023 09:10:32 AM


Document Has Been Signed on 03/05/2023 09:10 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: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: 6DATE:
03/04/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Licensee/Administrator Xiuyen ChenTIME COMPLETED:
11:55 AM
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Licensing Program Analysts (LPAs) Steve Chang and Ryker Heberle conducted an unannounced visit, and met with Licensee/Administrator Xiuyen Chen (ADM).LPAs observed 2 staff (S1, S2) working in the facility. LPAs obtained staff S1 and S2 working schedule ( 6:30AM - 7:30PM M - F, and Sat on call and working from 6:30AM - 6:30PM).Trash cans were observed with covers. Food supplies were observed to be sufficient. LPAs observed that ADM's non-fingerprint cleared husband was still residing at the facility. ADM stated that they have made an appoint to find alternative placement for her husband later today, at 12:30pm. Facility was observed to be adequately clean. LPAs observed emergency exits to be clear of obstruction.

LPAs spoke with the previous licensee (W1) about residing at backyard of the facility. W1 confirmed that her and her spouse (W2) live in the unit in the backyard of the facility. ADM informed LPAs that storage units in the back of the facility also belong to W1 and that ADM does not have access to storage sheds. LPAs confirmed that W1 is associated with the facility with an up to date fingerprint clearance, but were unable to confirm the fingerprint status of W2. W1 stated that it has been a long time since W2 received an up to date fingerprint clearance, but that they would be able to get W2 fingerprint cleared. During review of resident files, it was observed that 4 out of 6 residents in care did not have complete files.

LPAs checked the backyard with ADM. There were no obstruction blocked the walkway. During the course of the inspection, LPAs did not observe any toxic chemicals located outside of storage. LPAs did not observe any sharps located outside of locked drawers. Resident medication was observed to be locked and inaccessible to residents in care.

No citation noted during inspection. ADM requested an extension for POC on Type A citations from the report issued on 03/03/2023. Before conclusion of the inspection, ADM had to go to her husband's 12:30pm appointment. ADM gave facility staff member Monico Romero (S1) permission to sign on her behalf. Exit interview was conducted with S1. This report was provided to S1 for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2023
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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