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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202811
Report Date: 05/22/2024
Date Signed: 05/22/2024 04:06:23 PM

Document Has Been Signed on 05/22/2024 04:06 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:SWEET CARE HOME IN GILROYFACILITY NUMBER:
435202811
ADMINISTRATOR/
DIRECTOR:		YALUNG, ELAINEFACILITY TYPE:
740
ADDRESS:318 CHURCHILL PLACETELEPHONE:
(510) 458-7231
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 6CENSUS: 6DATE:
05/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Evelyn YalungTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual required - 1 year inspection. LPA met with lead staff, Evelyn Yalung. Administrator, Elaine Yalung is currently on vacation.

During visit, LPA toured the facility with staff to include the kitchen, living room, dining room, resident bedrooms, staff bedroom, bathrooms, and backyard. All exit routes are free and clear of obstruction. All staff present are fingerprint cleared and associated to the facility. Facility temperature maintained at 76 degrees Fahrenheit. Fire extinguisher last serviced on 08/10/2023. Facility has a carbon monoxide detector.

Sharp objects, chemicals, and disinfectants observed secured in the kitchen. Facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator temperature maintained at 40 degrees Fahrenheit. Freezer temperature maintained at 2 degrees Fahrenheit. Facility was advised. LPA observed the non-perishable foods are being locked by a child lock device. Staff state 1 of the residents goes through the non-perishable cabinet and grabs the items inside. Staff state resident is able to be redirected and they will remove the child lock devices. Facility was advised.

Resident bedrooms equipped with hospital beds, linens, adequate lighting, chair, and dresser. Bathroom equipped with shower chairs and grab bars. Hot water temperature in the resident bathroom maintained at 146 degrees Fahrenheit. Facility was advised.

SEE LIC809-C.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2024
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 5
Document Has Been Signed on 05/22/2024 04:06 PM - It Cannot Be Edited


Created By: Christine Dolores On 05/22/2024 at 03:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SWEET CARE HOME IN GILROY
FACILITY NUMBER: 435202811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the licensee did not comply with the section cited above in 2 counts in which 2 staff members are not provided 20 hours of annual training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2024
Plan of Correction
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Licensee will submit a written plan to ensure the section cited above will corrected to LPA Dolores by POC due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by not conducting quarterly drills in which the last drill was conducted in June 2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2024
Plan of Correction
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Licensee will submit a written plan to ensure the section cited above will corrected to LPA Dolores by POC due date.
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:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/22/2024 04:06 PM - It Cannot Be Edited


Created By: Christine Dolores On 05/22/2024 at 03:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SWEET CARE HOME IN GILROY
FACILITY NUMBER: 435202811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on obsevation, interview and record review the licensee did not comply with the section cited above in which the hot water temperature was maintained at 146 degree F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2024
Plan of Correction
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Licensee will submit a written plan to ensure the section cited above will corrected to LPA Dolores by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024


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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: SWEET CARE HOME IN GILROY
FACILITY NUMBER: 435202811
VISIT DATE: 05/22/2024
NARRATIVE
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LPA reviewed 3 resident's files. Resident files were complete, besides 1 resident (R1) whose file did not contain an appraisal/needs and services plan. 3 resident's centrally stored medications and centrally stored medication records were reviewed. A total of 4 medications were not accounted for in the residents centrally stored medication records. Facility was advised. LPA observed the resident orders for postural supports.

LPA reviewed 3 staff files. 3 out of 3 staff has an updated 1st aid certification, health screening report, and TB result. 3 out of 3 staff are fingerprint cleared and associated to the facility. LPA did not observe 20 hours of annual training for staff (S1) and (S2). Facility was advised.

Emergency drill was last conducted in June 2023. Facility was advised. LPA observed the facility has a complete 1st aid kit.

Deficiencies were cited today per California Code of Regulations, Title 22. See LIC809-D.

A civil penalty for repeat violation within a 12-month period is being assessed for the mount of $250. See LIC421FC.

This report was reviewed with lead staff, Evelyn Yalung and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/22/2024 04:06 PM - It Cannot Be Edited


Created By: Christine Dolores On 05/22/2024 at 03:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SWEET CARE HOME IN GILROY
FACILITY NUMBER: 435202811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)
(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the licensee did not comply with the section cited above in 4 counts which 4 medications were not accounted for in the residents centrally stored medication records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2024
Plan of Correction
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Licensee will submit a written plan to ensure the section cited above will corrected to LPA Dolores by POC due date.
Type B
Section Cited
CCR
87506(b)(17)(E)
(b) Each resident’s record shall contain at least the following information: (17) Documents and information required by the following: (E) Section 87463, Reappraisals; and

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the licensee did not comply with the section cited above in 1 out of 3 counts in which 1 resident's file did not contain an appraisal/needs and services plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2024
Plan of Correction
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Licensee will submit a written plan to ensure the section cited above will corrected to LPA Dolores by POC due date.
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:Sarah Yip
LICENSING EVALUATOR NAME:Christine Dolores
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024


LIC809 (FAS) - (06/04)
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