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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294351
Report Date: 09/11/2025
Date Signed: 09/12/2025 08:19:41 AM

Document Has Been Signed on 09/12/2025 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:		FERNANDEZ, DIVINAFACILITY TYPE:
740
ADDRESS:1187 PARK GROVE DRIVETELEPHONE:
(408) 941-9995
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY: 6CENSUS: 4DATE:
09/11/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Divina FernandezTIME VISIT/
INSPECTION COMPLETED:
06:39 PM
NARRATIVE
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On 09/11/25, LPA Steve Chang and LPM Romeo Manzano conducted an unannounced Case Management Visit-Incident during a complaint investigation.

On 08/08/25, the Department received a self-reported unusual incident and death reports that on 7/25/25, a resident (referred as R1) was sent to ER by home health nurse to check on R1's Foley Catheter due to R1 expressed a significant discomfort and pain level of 8/10. R1 was taken to the hospital due to infection and died on 08/02.

On 09/09/25, LPA/LPM interviewed S3. S3 stated that R1 was sent to ER via ambulance on 07/25 due to Home Health Nurse (HHN) was unable to replace R1's Foley catheter during visit. S3 stated HHN came to see R1 after staff reported of possible infection.

During today's inspection visit, LPA and LPM toured the facility. LPA and LPM met with resident (referred as R2) in bedroom#2. R2 was observed naked in bed wearing a undergarment. R2 noted to have long toenails on both feet. ADM stated that R1 does not have medical insurance but being visited with HHN; however, ADM did not consult a podiatrist, nor there is no appraisal about R2's feet and his/her behavior of being naked. R2's medication was also observed on R2's side table accessible, unlocked Staff (referred as S1) stated that he/she forgot to locked it after he/she administered medication. Two other medications were also observed accessible in the dining area, 2 medicines belongs to R3.

Continue on LIC809-C. Page 1 of 2.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Chihhsien Chang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2025
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
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 5
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: 09/11/2025
NARRATIVE
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At 3pm, LPA/LPA met with Administrator (ADM), LPA/LPM asked for a copy of facsimile report for R1's LIC624 wherein the Fax Call Report states an RCFE facility. ADM stated that she works at this RCFE facility since 2008 M to F, 8-5pm. According to LIC500 Personnel Summary report, ADM works at the facility M to F, 20 hours a week (8am-11am). ADM states she is available on the weekends and after 5pm. ADM stated that she will adjust her work hours and make herself available in the facility 20 hours a week.

LPA/LPM found out that staff who are scheduled to work 7pm to 7am sleeps in the facility living room. Facility does not have a designated staff bedroom in the facility. ADM stated that they will utilize the two vacant bedrooms temporarily.

LPM/LPA called licensee over the phone. LPA/LPM spoke to licensee to informed them about today's inspection visit. We discussed about the availability of the ADM and explained to them that ADM must be available during business hours, M to F 8-5pm. Licensee stated that they are in out of the country. LPA/LPM spoke to licensee's son, Ganty, to explain the purpose of visit and deficiencies.


Deficiencies cited during today's visit. See LIC809-D.

Exit interview was conducted with ADM. The report was provided to ADM for review. A copy of the report was provided to ADM.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Chihhsien Chang
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/12/2025 08:19 AM - It Cannot Be Edited


Created By: Chihhsien Chang On 09/11/2025 at 03:42 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: 09/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/18/2025
Section Cited
CCR
87465(h)(2)

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87465 Incidental Medical and Dental Care(h)(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
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Administrator (ADM) stated he/she will provide staff in service training on medication ensuring that medicines are always locked at all times. ADM stated he/she will submit a copy of staff in service training to CCL by POC date.
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On 09/11/25, During inspection, R1 to R3's prescribed medications were observed accessible/unlocked. Staff S1 and S2 had forgotten to locked it in the centrally stored cabinet after residents' administration. this poses an potential health, safety or personal rights risk to persons in care.
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Type B
09/18/2025
Section Cited
CCR87207

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87207 False Claims. No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
This requirement is not met as evidenced by:
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Administrator stated he/she will provide a written statement that he/she will not make any false claims and that he/she will comply with his/her working hours and also, licensee's son will be the back ADM who will submit his qualifications. ADM stated he/she will submit a copy of a signed written statement to CCL.
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Licensee and Administrator provided false or misleading statement regarding the facility and the service, The licensee and administrator stated that administrator will stay at the facility at 20 hours during business hours, but administrator is unable to be at the facility from 8:00AM - 5:00PM on Monday - Friday, this poses an 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.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Chihhsien Chang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 09/12/2025 08:19 AM - It Cannot Be Edited


Created By: Chihhsien Chang On 09/11/2025 at 05:17 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: 09/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/18/2025
Section Cited
CCR
87463(e)

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87463 Reappraisals. (e)The licensee shall immediately, or as soon as reasonably possible, bring any significant change in condition, as defined in Section 87101, Definitions, to the attention of the appropriate licensed medical professional and if applicable, other specialized care provider. Documentation of such communication shall be added to the resident's record and shall include:
This requirement is not met as evidenced by:
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Administrator stated the facility staff will provide care and supervision and to observe residents for any change in condition. The facility will update resident's care plan immediately and as necessary by submitting a written statement by ADM that care plan will be completed and adhered to by POC due date.
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Administrator did not observed the resident R1's change in condition and did not update R1's care plan, this poses an potential health, safety or personal rights risk to persons in care.
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Type B
09/18/2025
Section Cited
CCR87405(d)(1)

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87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...(1) Knowledge of the requirements for providing care and supervision appropriate to the residents.
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Administrator stated he/she will review his/her duties and responsibility as the ADM and to make to apply properly by submitting self certification to CCL by POC date.
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Based on overall deficiencies cited, ADM made false statement, ADM did not assess resident's care needs, medication accessibility and not spending 20 hours in the facility. This poses an 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.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Chihhsien Chang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2025


LIC809 (FAS) - (06/04)
Page: 5 of 5