435294351-12-15-2023-26-AS-CCHG-CYJM73-20231215082048

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435294351
Report Date: 12/14/2023
Date Signed: 12/15/2023 08:31:39 AM

Document Has Been Signed on 12/15/2023 08:31 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:	SWEET DREAMS CARE HOME LLC		FACILITY NUMBER:	435294351
ADMINISTRATOR:	JEAN JOSE		FACILITY TYPE:	740
ADDRESS:	1187 PARK GROVE DRIVE		TELEPHONE:	(408) 941-9995
CITY:	MILPITAS	STATE: CA	ZIP CODE:	95035
CAPACITY:	6	CENSUS: 8	DATE:	12/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Jean Jose and Gano Fici		TIME COMPLETED:	06:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit and met with Administrator (ADM) Jean Jose and Licensee (LCN) Gano Fici. LPA reviewed 5 residents files and 5 staff files.LPA toured the facility inside out with ADM. Licensee, Personal Rights posters and Administrator Certificate were observed at the main entrance. Living room, family room, dining room, kitchen, 6 resident bedroom rooms, 3 restrooms, and laundry room were inspected. 2 staff and 6 residents were observed in the facility. Two day perishable food supplies and Seven day nonperishable food supplies were observed sufficient. Room temperature was observed at 71 degree F. Hot water temperature was observed at 115 degree F. Refrigerator temperature was observed at 40 degree F. Freezer temperature was observed at 0 degree F. All of the bedrooms were observed with window screens and in good repair. Fire extinguisher was serviced on 11/28/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors were tested by ADM, and were working fine. Medications closet was observed locked. Knives closet and detergent closet were observed locked. One of the bathroom was observed without nonskid pad. The bedroom with resident using Oxygen administration was observed with the warning sign. First aid box was observed in the facility. Night lights were observed at the hallway. LPA toured the backyard with ADM. There were no obstacles blocked the exit. The facility last fire and emergency drill was conducted on 10/7/2023. Continue on LIC9099-C. Page 1 of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SWEET DREAMS CARE HOME LLC	FACILITY NUMBER: 435294351
	VISIT DATE: 12/14/2023

NARRATIVE

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During LPAs visit, LPA met with ADM Jean Jose and Licensee, Gano Fici. While conducting inspection with ADM, R1 asked ADM why he/she couldn’t go back to his/her bedroom wherein it was locked. ADM stated that the bedroom (garage converted into an office) has inverted doorknob. ADM stated that when LPA arrived at the facility, it was open. LPA asked to ADM and L1 to unlocked doorknob wherein both stated they did not have the key. Subsequently, L1 unlocked the door. LPA ask the ADM to unlocked the door. L1 stated his/her spouse has the key, L2. L2 was not in the facility.

Licensee was aware that the converted garage has been denied as a living quarter for staff or any individuals and can only be used as an office space by the Milpitas Fire Department. On April 2, 2013 the facility was cited for over capacity. On February 16, 2016 Licensee was informed that the garage could only be used an office and not a living space for residents or staff. In addition, during a Non-Compliance Conference Meeting on 12/2/2015 wherein the garage cannot be used as a living space. Licensee and Administrator must submit a plan of action to relocate R1 and R2 by end of business, 12/15/23.

LPAs interviewed ADM Jose Jean and staff (S1) who admitted that residents (R1 and R2) are sleeping in the office (converted garage) on 12/5/2023. During LPAs interview with Mr. Fici (licensee). Mr. Fici was asked if he admitted 2 residents beyond the allowed licensed capacity. Mr. Fici stated that there were no residents occupying the converted garage rather it is a storage for unused beds. LPAs inspected the converted garage wherein R1 and R2’s beds and personal belongings for R1 and R2, confirmed by ADM.

Prior to 4:52 PM, LPA Chang called Licensing Program Manager (LPM) Manzano to consult about over capacity. LPM requested to speak with the ADM. While LPM was on the phone with ADM Jean Jose about the over capacity, during the phone conversation, LPM overheard Mr. Fici stating, “tell we have 6.” ADM stated Mr. Fici said, ‘we have 6.’ Subsequently, ADM told the truth to LPA and LPM that on 12/5, Mr. Fici, has admitted new two elderly residents (R1 and R2) in the converted garage.

During interview with ADM and S1, LPAs also found out that ADM and S1 are sleeping in the couch and at the back of the house near the laundry area, based on their admissions. The facility does not have staff bedroom, therefore, the facility must have a awake night staff. On 2/16/2016, The facility licensee and ADM stated the noc shift staff are not allowed to sleep. LPA may issue more citations if more deficiencies were found.
Continue on LIC809-C. Page 2 of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

Page: 2 of 8

Document Has Been Signed on 12/15/2023 08:31 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SWEET DREAMS CARE HOME LLC	FACILITY NUMBER: 435294351
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview with 2 staff, ADM and S1 admitted the facility is using the converted garage(office) as a bedroom for residents R1 & R2. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/15/2023
	Plan of Correction
1 2 3 4	ADM will submit a picture documentation showing the office is no longer being used as a resident bedroom. ADM stated he will also send a letter of understanding stating no staff, volunteer or resident is allowed to sleep in the following areas without building permit and fire clearance such as but not limited storage room, living room, and office (converted garage).

Type A

Section Cited

CCR

87468.1(a)(1)

87468.1(a)(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews with 2 staff, staff confirmed that R1/R2 is in the office (converted garage). Staff stated the Licensee L1 did not have a key to open the office door while LPA was in the facility. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/15/2023
	Plan of Correction
1 2 3 4	Licensee will send a letter of understanding regarding the regulation and the licensee's role in ensuring residents are accorded dignity.

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: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

Page: 3 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SWEET DREAMS CARE HOME LLC	FACILITY NUMBER: 435294351
	VISIT DATE: 12/14/2023

NARRATIVE

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At approximately 7:30pm, Licensee L2 arrived at the facility. L2 was interviewed. L2 denied the facility admitted additional two residents beyond the approved license capacity. L2 stated the converted garage (office) is a storage room.

Exit interview was conducted with ADM and LCN. LIC809-D and Appeal Rights were attached. The report was provided to ADM and LCN for signature. A copy of the report was provided to ADM and LCN.

The annual required inspection will be continued at a later date.

Page 3 of 3.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

Page: 4 of 8

Document Has Been Signed on 12/15/2023 08:31 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SWEET DREAMS CARE HOME LLC	FACILITY NUMBER: 435294351
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87207

No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview with 2 staff members, the facility did not comply with their licensed capacity. The facility was over capacity by two residents. The facility providing misleading statements regarding the capacity.
	POC Due Date: 12/15/2023
	Plan of Correction
1 2 3 4	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

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

Page: 5 of 8

Document Has Been Signed on 12/15/2023 08:31 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SWEET DREAMS CARE HOME LLC	FACILITY NUMBER: 435294351
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87405(d)(1)(2)

(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews with facility staff, ADM and staff S1onfirmed the facility had residents R1 and R2 sleeping in the converted garage (office.) Staff also admitted that the facility was over capacity and had 8 residents, when the facility's capacity is 6 residents.
	POC Due Date: 12/15/2023
	Plan of Correction
1 2 3 4	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.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

Page: 6 of 8

Document Has Been Signed on 12/15/2023 08:31 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SWEET DREAMS CARE HOME LLC	FACILITY NUMBER: 435294351
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87204(a)

(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews with 2 staff, the facility currently has 8 residents. The facility is currently licensed for 6 residents. The facility is operating beyond the conditions and limitations specified on the license. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/15/2023
	Plan of Correction
1 2 3 4	Licensee will send LPA plan of action on how he/she will relocate the two surplus residents to comply with the conditions and limitations specified on the license.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

Page: 7 of 8

Document Has Been Signed on 12/15/2023 08:31 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SWEET DREAMS CARE HOME LLC	FACILITY NUMBER: 435294351
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(5)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, a bathroom at the end of the hallway on the left hand side, adjecent to the laundry room, did not have a non-skid mat in the bathtub. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/21/2023
	Plan of Correction
1 2 3 4	Licensee will send plan of action on how the facility will comply with the regulation requiring non-skid mats in the bathtubs/ showers.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

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