435202858-3-8-2023-26-AS-RMAO-CPS244-20230309160317

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202858
Report Date: 03/03/2023
Date Signed: 03/08/2023 08:48:31 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
11/22/2022 and conducted by Evaluator Simranjit Rai

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20221122133900

FACILITY NAME:	SENIOR SWEET CARE HOME		FACILITY NUMBER:	435202858
ADMINISTRATOR:	CHOW, MADELINE		FACILITY TYPE:	740
ADDRESS:	251 DELIA STREET		TELEPHONE:	(408) 649-3202
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95127
CAPACITY:	6	CENSUS: 6	DATE:	03/03/2023
		UNANNOUNCED	TIME BEGAN:	02:41 PM
MET WITH:	Licensee/Administrator Xiuyen Chen		TIME COMPLETED:	08:00 PM

ALLEGATION(S):

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Questionable Death: R1 had trouble breathing while eating cereal, milk came out of R1's nose and R1 subsequently expired.

INVESTIGATION FINDINGS:

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Licensing Program Manager (LPM) Romeo Manzano and Licensing Program Analyst (LPA) Simi Rai conducted an unannounced complaint investigation visit to deliver the investigation findings and met with Licensee/Administrator (ADM) Xiuyan Chen.

On 11/22/2022, the Department received a complaint of questionable death. On 11/22/2022, the Department conducted an initial investigation visit, and obtained resident physician report and appraisal needs and service plan.

Continued. See LIC9099-C, page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 1 of 8

Control Number 26-AS-20221122133900

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 03/03/2023

NARRATIVE

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On 11/22/2022, a questionable death allegation of a resident (R1) was investigated by the Department.

Based on investigation, interviews, and documents reviews, there is evidence to support there was a lack of care and supervision resulted on the death of R1 on 11/22/22 wherein R1 reported to having trouble breathing after R1 had eaten cereal, milk was coming out of R1’s nose and R1 subsequently expired.

The Santa Clara County Medical Examiner-Coroner’s Office determined that R1 had significant health issues and appeared to have died of natural causes. The Santa Clara Coroner’s Office or Law Enforcement Agencies did not investigate R1’s death because it was deemed a medical emergency, and R1 had no signs of trauma, and no evidence of foul play.

Based on review of R1’s death certificate listed R1’s cause of death as cardiopulmonary and congestive heart failure.

Based on investigation, 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 deficiencies or citations noted at today’s complaint investigation visit.

Exit interview conducted with Licensee/Administrator (ADM) Xiuyan Chen. A copy of this report was provided to Licensee/Administrator (ADM) Xiuyan Chen. 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 Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
11/22/2022 and conducted by Evaluator Simranjit Rai

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20221122133900

FACILITY NAME:	SENIOR SWEET CARE HOME		FACILITY NUMBER:	435202858
ADMINISTRATOR:	CHOW, MADELINE		FACILITY TYPE:	740
ADDRESS:	251 DELIA STREET		TELEPHONE:	(408) 649-3202
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95127
CAPACITY:	6	CENSUS: 6	DATE:	03/03/2023
		UNANNOUNCED	TIME BEGAN:	02:41 PM
MET WITH:	Licensee/Administrator Xiuyen Chen		TIME COMPLETED:	08:00 PM

ALLEGATION(S):

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9

Neglect/Lack of Care and Supervision: Facility did not seek immediate medical attention when R1 had trouble breathing while eating cereal, milk came out of R1 nose and R1 subsequently expired.

INVESTIGATION FINDINGS:

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Licensing Program Manager (LPM) Romeo Manzano and Licensing Program Analyst (LPA) Simi Rai conducted an unannounced complaint investigation visit to deliver the investigation findings and met with Licensee/Administrator (ADM) Xiuyan Chen.

On 11/22/2022, the Department received a complaint of questionable death.

On 11/22/2022, the Department conducted an initial investigation visit, and obtained resident physician report and appraisal needs and service plan.

Continued. See LIC9099-C, page 2 of 3.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 3 of 8

Control Number 26-AS-20221122133900

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 03/03/2023

NARRATIVE

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Based on interview and investigation, on 11/21/2022 at approximately 2:00AM, R1 was eating cereal, milk started coming out of R1’s nose which caused R1 to have trouble breathing.

Based on interviews conducted during investigation, R1 called FM to state that R1 was having trouble breathing. R1’s FM had advised R1 to knocked on staff’s door. R1 knocked on the door of S1. Staff (S1) on duty did not respond to R1. R1 reported to FM that staff did not respond. R1's FM called Administrator (ADM) right away to assist R1. ADM was not at the facility at the time of the phone call, and returned to the facility upon receiving FM’s phone call.

At approximately 2:30AM, ADM arrived at facility and could not get in because ADM forgot to bring the facility key. S1 on duty was not able to help because S1 was not awake. At approximately 2:40AM, R1 opened the door because S1 was asleep. ADM stated resident looked okay and sent R1 to R1's room. At 2:41AM, ADM called R1’s FM to report that R1 looked okay, but ADM tried to find non-emergency transportation to get R1 checked. At 2:44AM, ADM called 3 non-emergency transportation services and could not obtain transportation for R1. At 2:52AM, ADM called 911 while ADM was on the phone with 911, R1 suddenly dropped R1’s head and started leaning. ADM laid R1 on the floor and conducted CPR until paramedics arrived. R1 was sent to hospital by ambulance. R1 was pronounced dead at hospital at 03:39AM in the morning.

Based on record review, R1's physician report dated 12/02/21 specified that R1 was on a special diet (cardiac, minced and moist).

Based on interview with ADM, ADM stated has instructed staff at the facility to observe residents with problems swallowing small bites to allow residents to chew and swallow the food before the next bite. ADM also instructed staff to observe for signs and symptoms of chocking such as coughing while eating and drinking.

Continued. See LIC9099-C, page 3 of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 4 of 8

Control Number 26-AS-20221122133900

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 03/03/2023

NARRATIVE

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Based on interviews with ADM, and staff (S2-S3), staff acknowledged that R1 had trouble eating. ADM admitted that R1 ate at night unsupervised. ADM and staff are aware that R1 would get up every night and eat unsupervised while everyone asleep.
Although ADM was aware that R1 had difficulty swallowing food and R1 would get up at night to eat, ADM did not have awake staff on duty supervising R1. ADM stated that R1 would have been supervised eating, or had R1’s FM called 911, maybe R1’s wouldn’t have died.

Based on observations, records reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED.

Deficiencies are being cited. See LIC 9099-D.

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.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 5 of 8

Control Number 26-AS-20221122133900

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 A 03/04/2023 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health... This requirement was not met by:	1 2 3 4 5 6 7	Licensee to develop a plan of action in writing to prevent lack of supervision and care on residents, and provide immediate measures to residents in life-threatening medical crisis and submit to the Department by POC due date.
	8 9 10 11 12 13 14	Based on interviews and records review, on 11/21/2022, staff did not seek timely medical services to resident who passed away in the hospital after having difficulting breathing. This posed an immediate risk to the health, safety, or personal rights of the resident in care.	8 9 10 11 12 13 14
Type A 03/04/2023 Section Cited CCR 87415(a)	1 2 3 4 5 6 7	87415 Night Supervision (a) The following persons providing night supervision from l0:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid...shall be available as indicated below to assist in caring for residents in the event of an emergency.	1 2 3 4 5 6 7	Licensee to develop a plan of action in writing to ensure staff are available during night supervision to assist in caring for residents in an emergency and submit to the Department by POC due date.
	8 9 10 11 12 13 14	This requirement was not meet by: Based on interviews and record review, S1 was not available to assist in caring for residents in an emergency, which poses an immediate risk to the health, safety, or personal rights of the resident in care.	8 9 10 11 12 13 14

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 Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 26-AS-20221122133900

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 A 03/04/2023 Section Cited CCR 87405(d)(1)	1 2 3 4 5 6 7	87405 Administrator - Qualifications & Duties (d) The administrator shall have the qualifications... all requirements for an administrator shall apply. (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement is not met by:	1 2 3 4 5 6 7	Licensee will submit the Department with updated Administration Certification and a written plan to demonstrate Licensee's understanding of Title 22 policies pertaining to care and supervision of residents. Licensee to submit a written and signed statement understanding of this regulation by POC date.
	8 9 10 11 12 13 14	Based on investigation and as a result of R1’s death on 11/21/22, ADM is aware of R1’s difficulty swallowing who would get up at night to eat. ADM did not have a designated awake night staff to supervise R1. This posed an immediate risk to the health, safety or personal rights of the resident in care.	8 9 10 11 12 13 14
Type A 03/04/2023 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)... Personal Rights of Residents... shall have...: (4) To care, supervision & services that meet their individual needs & are delivered by staff that are sufficient in numbers, qualifications &competency to meet their needs.	1 2 3 4 5 6 7	Licensee will submit a written plan to demonstrate Licensee's understanding of Title 22 policies pertaining to this regulation and to submit a written and signed statement understanding of this regulation by POC date.
	8 9 10 11 12 13 14	This requirement is not met by: Based on investigation on the death of R1, ADM did not provide awake night staff to supervise R1 who has history of difficulty swallowing and waking up at night to eat unsupervised. This posed an immediate risk to the heath, safety or personal rights of the resident in care.	8 9 10 11 12 13 14

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 Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 26-AS-20221122133900

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 A 03/04/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met by:	1 2 3 4 5 6 7	Licensee stated she will hire additional staff and training to the staff. Licensee to submit a written and signed statement understanding of this regulation by POC date.
	8 9 10 11 12 13 14	Based on investigation, ADM designated Staff (S1) to supervise residents at the facility. S1 is ADM’s spouse. ADM stated S1 has issues with short term memory and other medical health conditions. This posed an immediate risk to the heathy, safety or personal rights of the resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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