015601204-5-16-2024-15-AS-LHOS-D5BVEG-20240516162220

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601204
Report Date: 05/16/2024
Date Signed: 05/16/2024 04:22:43 PM

Document Has Been Signed on 05/16/2024 04:22 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: 4	DATE:	05/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Isabella Joe, Administrator		TIME COMPLETED:	04:45 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 05/16/2024 around 11:30 AM, L. Holmes Licensing Program Analysts (LPA) L. Hall arrived unannounced to conduct a required Annual Inspection. LPA was greet by a Care Staff, and explained the purpose of the visit. Isabella Joe, Administrator (ADM), was contacted by phone and said she'd arrive in about 10 minutes; ADM arrived around 12:00 PM. The Administrator holds a certificate #600897740 that expired 11/28/23; Guardian is delayed in processing certificates. The facility’s fire clearance was approved for six (6); two (2) may be non-ambulatory residents. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, front yard, and back yard. The facility consists of four (4) bedrooms, a staff resting area/office, and three (3) bathrooms. All outdoor and indoor passageways are free of obstruction. A comfortable temperature was maintained at 74 degrees Fahrenheit (F). LPA observed lighting in all rooms to be adequate for the comfort and safety of all residents. The hot water temperature in the residents’ shared bathroom was measured at 107.7 degrees Fahrenheit (F). Residents’ bathrooms were equipped with grab bars and non-skid flooring. There was a 7-day supply of non-perishables and 2-days of perishable foods. Smoke detector and carbon monoxide units were in operating condition. Fire extinguisher was last serviced on 03//19/24. Emergency Disaster Plan to be updated. First aid kit was observed to be complete. Continued on LIC 809C...

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

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: 05/16/2024

NARRATIVE

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...continued from LIC 809.

- Post LIC 610D Emergency Disaster Plan
- Review client and resident files for signatures.
- Provide photos of cleared cob webs inside and outside of home
- Updated facility sketch
- LIC 200
- Update and post LIC 500

The following deficiency was observed.

-At 3:15 PM, LPA observed there was not an updated fire clearance inspection for two ((2) of the four (4) non-ambulatory residents.

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

Exit interview conducted, Appeal Rights and a copy of this report provided to Isabella Joe (ADM).

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/16/2024 04:22 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: 05/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(1)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (1) Nonambulatory persons. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews and records review, the licensee did not comply with the section cited above in 2 out of 4 residents being identifed as non-ambulatory and not approved on the fire clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/18/2024
	Plan of Correction
1 2 3 4	The licensee will submit an LIC 200 and an updated facility sketch for a non-ambulatory increase to CCLD for two (2) out of the four (4) residents being identifed as non-ambulatory.

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: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

LIC809 (FAS) - (06/04)

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