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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202858
Report Date: 06/29/2023
Date Signed: 06/29/2023 04:45:35 PM


Document Has Been Signed on 06/29/2023 04:45 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:XIUYAN CHENFACILITY TYPE:
740
ADDRESS:251 DELIA STREETTELEPHONE:
(408) 649-3202
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:6CENSUS: 6DATE:
06/29/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Xiuyan ChenTIME COMPLETED:
02:00 PM
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Licensing Program Analysts (LPAs) Steve Chang and Simi Rai conducted an unannounced Case Management - Legal/Non-compliance inspection and met with Administrator (ADM) Xiuyan Chen.

The purpose of the visit is to ensure that facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after a Non-Compliance Conference held on 03/28/23.

LPAs discussed with ADM regrading the plans of preventing lack of supervision and care on residents, ensuring staff are available during night shift, updating Administrator Certificate, understanding of the personal rights, ensuring adequate staff necessary for residents' care and supervision, and updating facility's emergency plan. LPAs discussed with ADM for updating facility policies and procedures of the standards for the facility operations.

LPAs discussed with ADM regarding providing staff training with observation and assessment of residents, personal rights, and mandatory reporting.

LPA obtained documents regarding the facility's written plan to address the prior deficiencies.

Based on the documents reviewed and interviewed conducted, the facility is in compliance.

No citations were noted today.

Exit interview was conducted with Administrator Xiuyan Chen. The report was provided to Administrator Xiuyan Chen for signature. A copy of the report was provided to Administrator Xiuyan Chen.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023
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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