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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202858
Report Date: 03/07/2023
Date Signed: 03/08/2023 08:39:32 AM


Document Has Been Signed on 03/08/2023 08:39 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:
03/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Xiuyen ChenTIME COMPLETED:
03:51 PM
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Licensing Program Analysts (LPAs) Steve Chang and Manuel Monter conducted an unannounced visit to follow up on the previous case management visit on 3/5/2023., and met with Administrator (ADM) Xiuyen Chen.

On 3/5/2023, LPA observed incomplete documents for staff and residents. ADM was advised during the visit to work on completing required licensing files for staff and residents.

On 3/5/20123, LPAs met with W1 and W2. W1 and W2 are former RCFE licensee and administrator of healthy living. W1 and W2 are the owners of the property. W1 and W2 have no access to the facility. LPA informed ADM to submit updated LIC500 to include the names of W1 and W2.

On 3/5/2023, ADM requested POC extension for all types A citation. LPAs informed licensee/ADM to submit POC before 3/7/2023 midnight.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023
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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