<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294351
Report Date: 01/04/2024
Date Signed: 01/04/2024 11:43:24 AM


Document Has Been Signed on 01/04/2024 11:43 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 LLCFACILITY NUMBER:
435294351
ADMINISTRATOR:JEAN JOSEFACILITY TYPE:
740
ADDRESS:1187 PARK GROVE DRIVETELEPHONE:
(408) 941-9995
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY:6CENSUS: 6DATE:
01/04/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:39 AM
MET WITH:Jean JoseTIME COMPLETED:
11:45 AM
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 Analysts (LPAs) Steve Chang and Manuel Monter conducted an unannounced case management visit- Annual continuation visit to inspect and evaluate the resolution for the prior deficiencies. LPAs met with Administrator (ADM) Jean Jose. LPA's observed 6 residents and two staff.

LPAs toured and inspected the garage, bedrooms and bathrooms. No residents were observed resides in the garage. LPAs reviewed the resident files.

LPAs reviewed and discussed the Plan of Correction with Administrator (ADM). The following deficiencies and plan of corrections were reviewed and cleared during the visit.

Type A, 87202 Fire Clearance (a) This deficiency was cited on December 14, 2023.
During today's visit, LPA's observed the garage not being used as a bedroom for residents or staff. LPA's also received the facility's plan of correction letter, which also included the pictures of the converted garage (office).

Type A, 87468.1 Personal rights of Residents in All Facilities (a)(1) This deficiency was cited on December 14, 2023. LPA received the facility's plan of correction letter.

Type A, 87207 False Claims, This deficiency was cited on December 14, 2023. LPA received the facility's plan of correction letter.

Type A, 87405 Administrator Qualifications and Duties (d)(1)(2) This deficiency was cited on December 14, 2023. LPA received the facility's plan of correction letter.

Page 1 out of 2.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 01/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/02/2024
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 3


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: 01/04/2024
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
26
27
28
29
30
31
32
Type A, 87204 Limitations Capacity and Ambulatory Status (a) This deficiency was cited on December 14, 2023. During today's visit, LPA's observed the facility had only 6 residents and the converted garage was not being used as a bedroom for staff or residents. The facility provided their plan of corrections.

Type B, 87303 Maintenance and Operation(e)(5) - This deficiency was cited on December 14, 2023. During todays visit, LPA's observed the facility bathtubs and showers had non-skid mats. LPA also received the facility's plan of action, with photo showing the bathroom adjacent to the laundry room has a non-skid mat.

LPA reviewed facility records for 8 residents. LPA reviewed 8 resident medications and centrally stored medication records. During a review of resident R3's records, LPA could not find R3's admission agreement. LPA's asked ADM for R3's admission agreement. ADM stated she doesn't know where it is and does not have a copy.

A deficiency is being cited during today's visit. This report was reviewed with ADM Jean Jose and a copy of the signed report was provided. Appeal rights were provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/04/2024 11:43 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: 01/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/11/2024
Section Cited
CCR
87507(d)

1
2
3
4
5
6
7
87507 Admission Agreements (d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications.
This requirement was not met as evidenced by;
1
2
3
4
5
6
7
The administrator stated she will send a plan of action on how the facility will retain residents's admission agreements. Administrator stated she will send plan to LPA by POC date, Janurary 11, 2024.
8
9
10
11
12
13
14
Based on record review, the facility did not have a copy of R3's admission agreement. LPA's asked ADM if she had the R3's admission agreement, and ADM stated she did not have a copy and cannot find it. This poses a potential heath, safety and personal rights risk to persons 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 ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3