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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202858
Report Date: 03/28/2023
Date Signed: 03/28/2023 05:10:36 PM


Document Has Been Signed on 03/28/2023 05:10 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: 4DATE:
03/28/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Xiuyan ChenTIME COMPLETED:
12:00 PM
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A Noncompliance meeting was conducted on 03/28/2023 at CCLD San Jose office. Present at the meeting were San Bruno Adult and Senior Care Regional Manager Vivien Helbling, Licensing Program Manager Romeo Manzano, Licensing Program Analysts Steve Chang, Simi Rai, Manuel Monter, and Ravi Patel, and facility Licensee Xiuyan Chen.

The purpose of the noncompliance meeting was to discuss the violations of Neglect/Lack of Care and Supervision wherein the 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.

As a result, the allegation is Substantiated. Deficiencies were cited for violations of Title 22 California Code of Regulations on 3/3/2023.

Facility licensee was informed during non-compliance meeting that additional civil penalties in the amount of $10,000 may be assessed pending review.

Noncompliance Conference Summary LIC 9111 and compliance plans were established during the meeting. The facility will begin a 2 year monitoring plan by licensing which includes more frequent licensing inspections.

LPA will follow up on the Fire Clearance for the property.

Report was reviewed with facility Licensee. A copy of this report, LIC 9111, was signed and provided by Licensee/Administrator Mrs. Chen during today's office visit.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2023
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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