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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200837
Report Date: 05/03/2023
Date Signed: 05/03/2023 06:31:48 PM

Document Has Been Signed on 05/03/2023 06:31 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: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:
05/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Billy Leung/Administrator and
Ricky Ng/Assistant Administrator 		TIME COMPLETED:
06:35 PM
NARRATIVE
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On this day, May 3, 2023, at 12:00 noon, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA was granted entry by staff, Joji Anabella 'Anabelle' Estavillo. LPA met with Billy Leung, administrator, and Ricky Ng, assistant administrator, and informed the reason for visit.

The facility has 3 buildings. LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, laundry and shower rooms, kitchen, dining and living areas, front, side and backyard. Facility has sufficient perishable and non-perishable foods. Fire extinguishers were observed fully charge with tags showed serviced January 24, 2023. Facility has carbon monoxide and smoke detectors that were tested and observed functional. Hot water temperature in one of the common bathrooms in the front building was tested and measured at 105 degrees Fahrenheit. Facility conducts disaster drills, and records showed last conducted January 20, 2023.

LPA reviewed 5 residents and 5 staff files, and interviewed 3 residents and 3 staff. Medications were checked and compared with records. Residents' cash resources checked.

LPA observed the following:
-at 12:22 pm, unlocked cabinet in the laundry room where cleaning supplies are kept
-at 2:00 pm, broken recliner, umbrella frame and shower chair in the backyard
-at 3:00 pm, resident (R1) LIC622 Centrally Stored Medication and Administration Record not properly completed; date filled does not match date filled on the label of the medication, and quantity received not recorded.
..continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2023
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: CHERRY BLOSSOM RESIDENTIAL CARE INC
FACILITY NUMBER: 019200837
VISIT DATE: 05/03/2023
NARRATIVE
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LPA received the following updated documents on this same day:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. LIC400 Affidavit Regarding Client/Resident Cash Resources
5. Proof of Surety Bond coverage

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with the administrator and assistant administrator.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/03/2023 06:31 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/03/2023 at 05:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CHERRY BLOSSOM RESIDENTIAL CARE INC
FACILITY NUMBER: 019200837

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above for unlocked cabinet in the laundry room where cleaning supplies are kept which poses an immediate safety risks to persons in care.
POC Due Date: 05/04/2023
Plan of Correction
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Administrator locked the cabinet and the laundry room immediately.
In addition, administrator will in-service the staff and submit proof by 5/04/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/03/2023 06:31 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/03/2023 at 06:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CHERRY BLOSSOM RESIDENTIAL CARE INC
FACILITY NUMBER: 019200837

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
80070 Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 5 LIC622s that is not properly filled-up which poses a potential health and personal rights risks to persons in care.
POC Due Date: 05/24/2023
Plan of Correction
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Administrator to have all the LIC622s checked for completeness and accuracy. Self-certification to be submitted by 5/24/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023


LIC809 (FAS) - (06/04)
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