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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294351
Report Date: 10/30/2024
Date Signed: 10/31/2024 08:19:32 AM

Document Has Been Signed on 10/31/2024 08:19 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SWEET DREAMS CARE HOME LLCFACILITY NUMBER:
435294351
ADMINISTRATOR/
DIRECTOR:		JEAN JOSEFACILITY TYPE:
740
ADDRESS:1187 PARK GROVE DRIVETELEPHONE:
(408) 941-9995
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
10/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:02 PM
MET WITH:Jean JoseTIME VISIT/
INSPECTION COMPLETED:
07:15 PM
NARRATIVE
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Licensing Program Analysts ( LPAs) Steve Chang and Mita Partoza conducted an unannounced case management inspection visit and met with Administrator (ADM) Jean Jose. ADM stated that licensee is not in the facility is out of the country approximately beginning of July, 2024 and have not returned since then.

ADM stated that there are currently 6 residents in the facility. 1 Out of 6 is at the hospital and 5 out 6 are present and resting in their room. 1 out of 6 is ambulatory, 2 of 6 are under hospice care. 3 out 6 are non-ambulatory. 1 out of 6 is in the hospital.

LPAs stated the purpose of the visit is to conduct a case management visit ensure that facility is compliant with California Code of Regulation (CCR) Title 22 such as the condition of the physical plant, staffing requirement, the living condition of the resident, and if the garage is being used as a room to accommodate a resident.

LPA toured the facility inside and outside with ADM such as living room, kitchen, dining room, 3 restrooms and 6 residents bedrooms. 6 of 6 resident's room are sanitary, organized and has sufficient storage. One of the resident's restroom sink drawer cabinet was not closing properly and can be a tripping hazard. Bedroom #6 at the end of the hallway has a broken window glass and is missing a window screen. S1 stated that there are window air conditioner system for each room. However R1 does not want the window air conditioner. S1 stated that the screen window will be re-installed. The facility is equipped with working smoke and carbon monoxide alarm system.

The front yard and backyard were inspected. LPAs observed the following, at the front yard is a vehicle that is not operational covered by a gray tarp. S1 stated that the vehicle has been parked for a number years prior to her being employed at the facility, LPAs toured the facility garage and observed a sleeper couch inside and clothing items. S1 stated that the staff use the garage as their place to rest, while the licensee is out of the country. LPAs observed a functioning bathroom with shower inside the garage used by the staff.
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Romeo ManzanoTELEPHONE: (408) 277-1289
Chihhsien ChangTELEPHONE: (408) 904-9843
DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: SWEET DREAMS CARE HOME LLC
FACILITY NUMBER: 435294351
VISIT DATE: 10/30/2024
NARRATIVE
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LPA observed backyard has multiple storage, one storage was missing a door. There was piled household items that are no longer in use, a recliner that is no longer in used, 2 grills that are not used, a bucket of standing water, piled wood planks, a non operating refrigerator by the side of the building, medical equipment that are no longer in use are stored inside an open storage. The facility has emergency exit gates on both sides. on the right side the gate is not attached and not functional and another plank of wood was used to put weight on the half gate to prevent the gate from falling. The walkway is obstructed by garden chairs. The bank fence needs reinforcement and 3 planks are not secured properly.

LPA reviewed facility record and found that the facility's last disaster training was done on 8/14/2024.
Based on review of the facility file, the facility has a total of 5 staff. Based on record review there is a shortage of staff for both day and night shift. S1 stated that he/she is the day and nocturnal shift (NOC) shift and sleeps on the couch so that he/she can hear the resident when they push their pendant when assistance is needed. The LIC 500 does not reflect the true hours and days that staff are working. S1 stated that when other staff are on break he/she covers the two hour breaks between shift.

LPA reviewed resident's records including but not limited to centrally stored medication and destruction record (CSMDR), physician's report and appraisal needs and services plan, and observed that 2 out of 6 are under hospice care, 4 out of 6 are complete and updated.

LPA reviewed 2 staff records and observed records to be complete an updated, certificates are up to date, compliant with training current and up to date. Staff are fingerprint/criminal background cleared.

Licensee did not notify the Community Care Licensing (CCL) of their absence to ensure that the facility has general supervision over the affairs, policies concerning it's operations to conform with regulations.

Deficiencies are cited during today's visit based on California Code of Regulation CCR, Title 22 87303 (a) and 87411 (a). An exit interview was conducted with ADM Jean Jose and a copy of the report was provided.

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SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/31/2024 08:19 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
CENTRAL COAST CR/RES, 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: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2024
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
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ADM stated that she will notify the licensee of the broken glass window, the piled up household items, unused medical equipement, & applicance. ADM will submit a written plan of correction on how the facility will ensure that facility is maintained and in good repair at all times by the due date
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Based on observation the LIC did not comply with the above by not maintaining the facility clean, sanitary and in good repair. LPAs observed piled up household items no longer in use,broken window glass, non-operating appliances, vehicle, and medical equipments and pile of woods.
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con't. Which can serve as a place for rodents and other animals to breed, which pose/poses an immediate, health, safety and personal rights risks to persons in care.
Type A
10/31/2024
Section Cited
CCR87411(a)

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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 as evidenced by:
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ADM stated that he/she will notify the LIC regarding staffing shortage. ADM will submit a written plan of correction on how the faciltiy will address staffing shortages by the due date.
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Based on interview and record review the LIC did not comply by not having sufficient personnel who are competent to provide necessary services. LPAs interviewed ADM/S1 and stated that he/she cover other staff breaks, and is the overnight staff. Based on review and assessment of LIC 500,
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con't. the facility does not have a night staff and have no sufficient coverage for breaks and days off.
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) 277-1289
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/31/2024 08:19 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
CENTRAL COAST CR/RES, 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: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/06/2024
Section Cited
CCR
87205(a)

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87205(a) Accountability of Licensee Governing Body (a) The licensee, whether an individual or entity ...shall excercise general supervision over the affairs of the licensed facility ... policies..in confrmance with these regulations and welfare of the individuals it serves:
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ADM stated that he/she will notify the LIC of the need to inform CCL of their prolonged absence due to issues that may arise at any time. ADM will submit a written plan of correction on how the facility will ensure that general supervision and conformance to regulations is followed.
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This requirement is not met as evidenced by: Based on interview, the LIC did not notify CCL of their prolong absence leaving the facility without proper general supervision to conform with regulations and welfare of the individualls in the facilty whic pose/poses a potential health, safety and personal rights
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con't to persons in care.

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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) 277-1289
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4