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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202858
Report Date: 03/03/2023
Date Signed: 03/08/2023 08:46:25 AM


Document Has Been Signed on 03/08/2023 08:46 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
CENTRAL COAST CR/RES, 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:
03/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:21 PM
MET WITH:Licensee/Administrator Xiuyan ChenTIME COMPLETED:
08:00 PM
NARRATIVE
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Licensing Program Manager (LPM) Romeo Manzano and Licensing Program Analyst (LPA) Simi Rai conducted a Case Management visit during a Compliant investigation. LPM and LPA met with Administrator (ADM)/Licensee Xiuyan Chen.

At this time, there are 2 staff members (S1 and S2) at that facility to care and supervise the residents. Licensee will submit LIC 500 Personnel Summary to the Department by tomorrow March 4th 2023 before midnight.

Per ADM, staff (S1) is currently living at the facility who is not fingerprint cleared and not associated to the facility. Per ADM, an exemption letter has been sent to the Department and it is under review. LPM stated S1 cannot reside in the facility while the Department is deliberating the decision and cannot work at the facility. As a result, the facility has been cited under 87355 Criminal Record Clearance.

Licensee will submit copies of LIC 602 Physician Report, Functional Capability Form and Pre-Placement form for S1 from previous facility.

Deficiencies are being cited. See LIC 809-D.

A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500), for staff (S1) working at the facility without exemption. Please see LIC 421BG.

Exit interview conducted with Licensee/Administrator (ADM) Xiuyan Chen. A copy of this report was provided to Licensee/Administrator (ADM) Xiuyan Chen. Appeal Rights was provided.This report was delivered to Licensee/Administrator (ADM) Xiuyan Chen at her second location at ARF Sweet Care Home (3283 Mount Everest Drive, San Jose, CA 95127) due to ADM supervising residents at second location.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 03/08/2023 08:46 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: SENIOR SWEET CARE HOME
FACILITY NUMBER: 435202858

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/06/2023
Section Cited

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 87355 Criminal Record Clearance: (e) All individuals subject to a criminal record review ... shall prior to working, residing or volunteering in a licensed facility. (1) Obtain a California clearance or a criminal record exception....
This requirement is not met by:
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This poses an immediate health, safety, or personal rights risk to a person in care. Licensee agreed and understood staff and individuals residing at the facility need to have criminal record clearance or execption.
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Based on interview and observation, S1's husband (S2) worked until 2/24/2023 and resides at the facility without a criminal background clearance and S1 stated S2 needs criminal record exemption.
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Licensee to submit a written and signed statement understanding of this regulation by POC date.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2023
LIC809 (FAS) - (06/04)
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