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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202811
Report Date: 05/05/2021
Date Signed: 05/06/2021 09:31:51 AM

Document Has Been Signed on 05/06/2021 09:31 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 CARE HOME IN GILROYFACILITY NUMBER:
435202811
ADMINISTRATOR:YALUNG, ELAINEFACILITY TYPE:
740
ADDRESS:318 CHURCHILL PLACETELEPHONE:
(510) 458-7231
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 6DATE:
05/05/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Elaine YalungTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Joanne Roadilla conducted a pre-licensing tele-inspection visit today via Zoom. The Department has suspended on site visits due to COVID-19 shelter in place order by Governor Newsom. The home is currently licensed as Mary's House – 435294190, with 6 residents in care. The pre-licensing is for a change of ownership. LPA met with Administrator (ADM) Elaine Yalung.

At around 3:40pm, LPA toured the facility virtually lead by ADM. LPA observed COVID-19 related posters at the entrance to promote social distancing and infection control. A screening station is located by the entry door for checking temperature of any visitors, residents or personnel coming in through the facility. There were complaint, ombudsman, and resident's bill of rights posters observed in the hallway.

The thermostat registered the room temperature at 73 deg F. The facility is equipped with connected combination smoke and carbon monoxide detectors, the one located in the living room was tested and observed working. Fire extinguishers were observed by the hallway and in the living room and were last serviced on August 13, 2020. The kitchen, dining and living room were observed in good repair. The water temperature in the kitchen was measured at 117 degrees F. LPA observed at least a 2-day supply of perishable and 7-day supply of non-perishable foods. Continued on LIC809-C.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Joanne Roadilla
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2021
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 CARE HOME IN GILROY
FACILITY NUMBER: 435202811
VISIT DATE: 05/05/2021
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A complete first aid kit was inspected. Centrally stored medications, cleaning supplies and other toxic substances were observed in locked cabinets. PPEs were observed by the laundry area next to the kitchen. Resident bedrooms were observed in good repair, fully furnished, with clean linens and adequate lighting. Bathrooms were observed clean and equipped with grab bars and non-skid mats. The backyard was inspected. All outdoor and indoor passageways were observed clear and free of obstruction. No bodies of water observed.

At around 4:30pm, review of Component III was completed with ADM. There were no issues noted during the pre-licensing tele-inspection. The physical plant is approved pending the completion of Centralized Application Bureau (CAB) review of the facility application. Exit interview conducted with and copy of report sent to Elaine Yalung for review and signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Joanne Roadilla
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021
LIC809 (FAS) - (06/04)
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