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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200837
Report Date: 05/05/2022
Date Signed: 06/06/2022 08:49:35 AM

Document Has Been Signed on 06/06/2022 08:49 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:CHERRY BLOSSOM RESIDENTIAL CARE INCFACILITY NUMBER:
019200837
ADMINISTRATOR:LEUNG, BILLYFACILITY TYPE:
735
ADDRESS:241 CHERRY WAYTELEPHONE:
(510) 276-6003
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 23CENSUS: 22DATE:
05/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:25 PM
MET WITH:Billy Yeung/Administrator and
Ricky Ng/Co-administrator 		TIME COMPLETED:
07:05 PM
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA met with Billy Yeung, administrator, and Ricky Ng, co-administrator, and informed the purpose of visit.

Facility has LIC808 Mitigation Plan on file.

LPA toured the facility inside out. The facility has 3 buildings. LPA inspected the living rooms, dining areas, kitchens, bathrooms, bedrooms,laundry rooms, side and backyard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days.

LPA observed screening station by the front entrance with hand sanitizer and no touch temperature probe. Visitor's temperature and symptom checks are done at entry and recorded. Residents and staff are screened for COVID-19 symptoms and temperature checked daily. Supplies of PPEs checked. All staff were fit tested for N95 respirators. All trash bins were observed with foot operated pedal lids. Antigen test kits are readily available.

Fire extinguisher checked and observed fully charge with tag showed serviced January 14, 2922. First aid kit was observed complete with manual. Hot water temperature in one of the common bathrooms in the front building tested and measured at 107.4 degrees Fahrenheit.

LPA observed the following:
1. No cough/sneeze etiquette posters in the common areas.
2. Paper towels in the two bathrooms were sitting on lavatory sinks.
3. Disposable gowns not sufficient for 30 days for 13 staff.

......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2022
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: CHERRY BLOSSOM RESIDENTIAL CARE INC
FACILITY NUMBER: 019200837
VISIT DATE: 05/05/2022
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LPA verified and administrator stated they don't check visitors for proof of COVID-19 vaccination.

LPA obtained the following updated documents on this day.
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan
4. Proof of Surety Bond coverage

No deficiency cited during today's visit.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
LIC809 (FAS) - (06/04)
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