015601204-5-26-2022-15-AS-LHAL-CESVSE-20220526164126

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601204
Report Date: 05/26/2022
Date Signed: 05/26/2022 04:41:40 PM

Document Has Been Signed on 05/26/2022 04:41 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	LUCKY GARDEN CARE HOME		FACILITY NUMBER:	015601204
ADMINISTRATOR:	JOE, ISABELLA		FACILITY TYPE:	740
ADDRESS:	42745 PEACHWOOD STREET		TELEPHONE:	(510) 673-6399
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY:	6	CENSUS: 3	DATE:	05/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Guangyong Cheng, Administrator		TIME COMPLETED:	04:50 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 5/26//2022 at 3:20PM, Licensing Program Analysts (LPAs) L. Hall and L. Fici arrived unannounced to conduct an Infection Control Inspection. LPA met with Guangyong Cheng, Caregiver, and explained the purpose of the visit. Administrator, Isabella Joe arrived at 3:35PM. Upon entry, LPAs temperatures was checked. LPAs observed screening station that contained hand sanitizer, sign-in book and COVID signage. LPAs toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, and back yard. LPAs observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing poster. Hot water temperature in the shared residents' bathroom was measured at 111.8 .degrees Fahrenheit. Fire extinguisher was purchased February 2022.. During record review, LPA observed facility has a copy of Mitigation Plan on file. LPA observed food, PPE and paper supplies are sufficient. The following forms are to be updated and submitted to CCLD by 6/2/2022: -LIC500 Personnel Report -LIC308 Designation of Administrative Responsibility Continued on LIC809C

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 015601204
	VISIT DATE: 05/26/2022

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
26
27
28
29
30
31
32

Continued from LIC809.

-LIC610E Emergency Disaster Plan

The following deficiency was observed.

-At 3:55PM, LPAs observed there was not any non-skid mats in either three (3) bathrooms.

he following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 05/26/2022 04:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 015601204
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(5)

87303 Maintenance and Operation (5) Non-skid mats or strips shall be used in all bathtubs and showers This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having non-skid mats in bathtub/shower which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/02/2022
	Plan of Correction
1 2 3 4	Administrator agreed to purchase non-skid mats for all three (3) bathrooms and send photo of mats in bathtub/shower to CCLD by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3