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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294351
Report Date: 12/16/2024
Date Signed: 12/16/2024 11:32:26 AM

Document Has Been Signed on 12/16/2024 11:32 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: 6CENSUS: 5DATE:
12/16/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator Jean JoseTIME VISIT/
INSPECTION COMPLETED:
11:35 AM
NARRATIVE
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Licensing Program Analyst Manuel Monter conducted an unannounced case management -other, regarding an eviction for resident referred to as R1. LPA met with Administrator Jean Jose and explained the purpose of the visit.

On November 16, 2024, the facility provided an eviction letter to R1; stating the reason for the eviction was due to the change in R1's status from non-ambulatory to bedridden.

On December 16, 2024, LPA Manuel Monter conducted an unannounced case management visit. LPA observed resident R1 in his/her bedroom. LPA observed R1 was able to make slight repositioning from left to right. LPA observed when ADM was assisting R1 with repositioning, R1 was holding on to trapeze bar above his/her bed to help in repositioning him/herself.

LPA interviewed R1. R1 stated he/she can move him/herself slightly to the left and right. R1 stated he/she also uses the trapeze bar above his/her bed to reposition him/herself slightly.

ADM stated she was informed that R1 had become bedridden around November 12, 2024. ADM stated she accepted R1 back to the facility, knowing the bedroom which has been cleared for bedridden use is already occupied by a non-ambulatory resident in his/her care. LPA requested to review R1's Preplacement appraisal. ADM stated she does not have one for R1. ADM stated R1 was seen before he/she moved in but they did not document the actual pre-placement appraisal. ADM stated she will be notifying the local fire department regarding the bedridden residents who are currently under their care.

Deficiency is being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator Jose & a copy of the signed report was provided. Appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
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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Document Has Been Signed on 12/16/2024 11:32 AM - It Cannot Be Edited


Created By: Manuel Monter On 12/16/2024 at 11:08 AM
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 DREAMS CARE HOME LLC
FACILITY NUMBER: 435294351

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/23/2024
Section Cited
CCR
87457(c)

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87457 Pre-admission Appraisal - General (c)Prior to admission... resident's suitability for admission shall be completed... an appraisal of his/her individual service needs ...
This requirement was not met as evidenced by;
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ADM stated she will send a written letter of understanding regarding the regulation. ADM stated she will send this letter of understanding to LPA, by POC date, December 23, 2024.
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Based on interview and record review, ADM stated the facility did not document the pre-admission apprisal for resident R1. This poses a potential health, safety or personal rights risk to persons in care.
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Type B
12/23/2024
Section Cited
CCR87202(a)

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87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved ... Prior to accepting or retaining any of the following types of persons,... obtain an appropriate fire clearance approved ... the State Fire Marshal. This requirement was not met as evidenced by
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ADM stated she will send a written letter of understanding regarding the regulation. ADM stated she will send this letter of understanding to LPA, by POC date, December 23, 2024.
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Based on interviews and records reviewed, resident R1 is a bedridden resident who resides in bedroom #6. Based on a review of the facility's fire cleareance, bedroom #6 is not cleared for the use of a bedriddent resident. This poses a potential health, safety or personal rights risk 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 Manzano
LICENSING EVALUATOR NAME:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2024


LIC809 (FAS) - (06/04)
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