<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601204
Report Date: 05/28/2021
Date Signed: 05/28/2021 04:54:48 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:LUCKY GARDEN CARE HOMEFACILITY NUMBER:
015601204
ADMINISTRATOR:JOE, ISABELLAFACILITY TYPE:
740
ADDRESS:42745 PEACHWOOD STREETTELEPHONE:
(510) 673-6399
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:6CENSUS: 6DATE:
05/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:49 PM
MET WITH:Isabella Joe, AdministratorTIME COMPLETED:
05:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 5/28/2021 at 1:49PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct an Infection Control Inspection. LPA met with staff, Guangyong Cheng and explained the purpose of the visit. Administrator, Isabella Joe arrived 30 minutes later.

Upon entry, staff did not perform COVID-19 screening for LPA. Hand sanitizer was observed near the front door and also throughout the facility. LPA toured facility including but not limited to common areas, hand washing stations, bedrooms, and kitchen. LPA observed no cough etiquette, physical distancing, and signs & symptoms posted in the common areas. All bathrooms were missing paper towels. Hand washing were posted at hand washing stations in Chinese. LPA was informed that most residents were Chinese.

During record review, LPA observed visitors log and temperature log. LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE, food and paper supplies are sufficient.

Facility was given Technical Assistance regarding infection control guidelines and documented on LIC9102.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
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 9