015601204-4-21-2023-15-AS-LFII-CR4THU-20230421144520

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601204
Report Date: 04/21/2023
Date Signed: 04/21/2023 02:45:28 PM

Document Has Been Signed on 04/21/2023 02:45 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: 5	DATE:	04/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	JOE, ISABELLA- Licensee		TIME COMPLETED:	03:00 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 4/21/2023 starting at 9:25 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with JOE, ISABELLA- Licensee and explained the purpose of the visit. The licensee administrators certificate is valid and expires on 11/28/2023. The facility’s fire clearance was approved for all four (4) ambulatory residents, two (2) non- ambulatory residents and two (2) hospice waivers. Upon entry, LPA observed two (2) staff and five (5) residents present during inspection. Starting at 10:20 AM, LPA toured facility with licensee including but not limited to four (4) bedrooms, three (3) bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 1 bedroom is private, and 3 bedrooms are shared. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 68 Degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents'. The hot water temperature in residents’ common area bathroom was measured at 107.6 Degrees Fahrenheit. Residents’ bathrooms are equipped non-skid mats. There is a minimum of one-week supply of nonperishable and 2-day supply of perishable foods. Sharps and toxins were locked and inaccessible to residents'. Smoke detectors and carbon monoxide detector were in operating condition. Fire extinguisher was observed last serviced on 3/4/2023. First aid kit was observed to be complete. Continue on Lic809-C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LUCKY GARDEN CARE HOME	FACILITY NUMBER: 015601204
	VISIT DATE: 04/21/2023

NARRATIVE

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Continued from Lic809

Starting At 11:20 AM, LPA reviewed 2 of 2 staff records. At 12:12 PM, LPA reviewed 5 of 5 residents' record. At 1:15 PM, LPA attempted to review a sample of 5 of 5 residents' medications, however, residents MAR was not filled out for the year of 2023 and LPA was not able to verify residents' medication.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

At 11:30AM, LPA observed S1 with no CPR training.
At 11:40AM, LPA observed S2 with no First aid and CPR training in his file.
At 1:10PM, LPA observed no MAR created for R1, R2, R3, R4, AND R5 for the year of 2023.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 4/5/2023:

· LIC 308 Designation of Administrative Responsibility
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 Pages)
· Liability Insurance

Exit interview conducted with Licensee, and a copy of this report provided along with appeal rights.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/21/2023 02:45 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: 04/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. 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 by not having current CPR training and allowing S2 to work with resident with no First aid and CPR training on file which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/22/2023
	Plan of Correction
1 2 3 4	Licensee agreed to obtain a certificate for first aid and CPR for S1 and S2 and to submit a copy to CCL by POC due 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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 04/21/2023 02:45 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: 04/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not maintaining an Lic501 (personnel record) for S2 in staff file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/28/2023
	Plan of Correction
1 2 3 4	Submit a copy to CCL by POC due date, licensee agreed to have S2 fill out an Lic501 (Personnel record) and to maintain it in his file for record review.

Type B

Section Cited

CCR

87465(h)(4)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not having MAR fill out for R1, R2, R3, R4, and R5 kept in their file for review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/28/2023
	Plan of Correction
1 2 3 4	Licensee agreed to fill out MAR sheets for all residents and to submit a copy to CCL by POC due date.

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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

LIC809 (FAS) - (06/04)

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