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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202858
Report Date: 03/05/2023
Date Signed: 03/07/2023 12:15:40 PM


Document Has Been Signed on 03/07/2023 12:15 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
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:
03/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Xiuyen ChenTIME COMPLETED:
10:59 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. S1 stated S1 and S2 on call today. S1 stated both S1 and S2 works from 6:30AM - 6:30PM today.

LPAs toured the facility with ADM. LPAs checked the food supplies. 2 days perishable food supplies and 7 days nonperishable food supplies were observed sufficient. Medication closet, detergents closet, and knives closet were observed locked. Client files and staff files were observed incomplete.

LPAs inspected the backyard. LPAs knocked the door of the room that previous owners (W1 and W2) are residing in. W1 opened the door for LPAs. LPAs spoke with W1 and W2. W1 and W2 confirmed that they are not receiveing any care from staff at the facility.

LPAs toured kichen, dining room, living room, backyard, 3 resident bedrooms, 1 staff bedroom, laundry room, and 2 bathrooms with ADM. 6 residents were observed in facility.

ADM requested to extend the deadline of POC to 3/5/2023.

No deficiencies cited during this inspection. Exit interview was conducted with ADM. The report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2023
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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