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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294351
Report Date: 01/23/2025
Date Signed: 01/23/2025 04:39:34 PM

Document Has Been Signed on 01/23/2025 04:39 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 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: 4DATE:
01/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Administrator Jean JoseTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Marcela Yanez & Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Jean Jose. During the visit, LPA observed 4 residents and 2 staff. LPA explained the purpose of the visit.

LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 3 restrooms and 6 residents bedrooms. The front yard and backyard were inspected. LPA toured the facility garage, which is being used as a storage area. There was no obstruction to block the walkways.

While touring the backyard, LPA's observed several sheds in the backyard. LPA observed a shed in front of the storage shed in the backyard. Both of these sheds were not locked and contained tools and other toxic materials such as; WD-40 and a paint can.(Photographs were taken.) While, touring the side of the home next to the garage/office, LPA observed a gallon of windshield washer fluid and accessible. (Photographs were taken.) LPA's also observed a shovel next to the exit to the front yard, directly next to the garage/office. ADM locked both storage sheds and secured the windshield washer fluid during visit.

While touring the home, Licensee arrived to drop off supplies. LPA's advised Licensee regarding some of the clutter around the facility. LPA's advised Licensee that he/she must maintain the facility clean and in good repair. LPA's noted some of the clutter LPA's observed in the laundry room area and in the backyard. Licensee stated he/she is in the process of de-cluttering. Licensee stated he agreed and understood LPA's observation regarding the clutter.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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
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: 01/23/2025
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Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 108 degrees F in resident bathrooms.

Fire extinguisher was serviced November 28, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on December 15, 2024.

LPA reviewed facility records for 3 staff and 4 residents. LPA reviewed 4 resident medications and centrally stored medication records. LPA conducted interviews with 1 staff and 3 residents.

LPA provided ADM with CDSS Flyer, "Important updates to Dementia Care and Miscellaneous Changes, effective January 1, 2025."

A deficiency and technical violation is being cited during today's visit. This report was reviewed with Administrator Jean Jose and a copy of the signed report and appeals rights was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Marcela Yanez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/23/2025 04:39 PM - It Cannot Be Edited


Created By: Marcela Yanez On 01/23/2025 at 04:11 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 DREAMS CARE HOME LLC
FACILITY NUMBER: 435294351

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above.LPA observed two sheds in the backyard were not locked and contained tools and other toxic materials such as; WD-40 and a paint can. While, touring , LPA observed next to the side of the home next to the garage/office, a gallon of windshield washer fluid accessible and a shovel. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/24/2025
Plan of Correction
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ADM locked the storage shed during visit and secured winshield wiper fluid during visit, ADM will submit a letter of understanding regarding the importance of keeping toxics/detergents/other hazardous objects such as tools should be inaccessible to residents in care. ADM stated will send POC by due date January 24,2025.
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:Romeo Manzano
LICENSING EVALUATOR NAME:Marcela Yanez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2025


LIC809 (FAS) - (06/04)
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