<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200837
Report Date: 05/16/2024
Date Signed: 05/16/2024 07:00:21 PM

Document Has Been Signed on 05/16/2024 07:00 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/
DIRECTOR:		LEUNG, BILLYFACILITY TYPE:
735
ADDRESS:241 CHERRY WAYTELEPHONE:
(510) 276-6003
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 23CENSUS: 21DATE:
05/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Administrator Billy Leung/Administrator and
Assistant Administrators Ricky Ng and Cody Ng		TIME VISIT/
INSPECTION COMPLETED:
07:05 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
Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Billy Leung, administrator, and Ricky Ng and Cody Ng, assistant administrators, and informed the reason for visit.

The facility has 3 buildings. LPA inspected the facility inside and out including but not limited to kitchen, dining areas, bathrooms, laundry and shower rooms, living room areas, front, side and backyard. LPA randomly selected for inspection total of 8 bedrooms in 3 buildings. Facility has sufficient perishable and non-perishable foods. Fire extinguishers were observed fully charge with tags showed serviced August 12, 2023. Facility has 2 in 1 carbon monoxide and smoke detector that was tested and observed in operating condition, Hot water temperature in one of the common bathrooms in Bldg # 1 and Bldg # 2 were tested and measured at 105.4 and 115.3 degrees Fahrenheit. Facility conducts fire and earthquake drills every other month, and records showed last conducted April 16, 2024 and March 25, 2024 respectively.

LPA reviewed 5 residents and 5 staff files, and interviewed 3 residents and 3 staff. Medications were checked and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records, Residents' P&I records checked.

LPA observed the following:
-at 1:15 p.m, full bed rails in R1's bed.
-from 4:30 pm to 5:30 pm, residents have no LIC9172 Functional Capability Assessment.


....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
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)
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: CHERRY BLOSSOM RESIDENTIAL CARE INC
FACILITY NUMBER: 019200837
VISIT DATE: 05/16/2024
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
LPA received copies of the following updated/current documents on this same day:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. Proof of Surety Bond coverage

Administrator to submit an updated LIC400 Affidavit Regarding Client/Resident Cash Resources by May 30, 2024.

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 administrators.

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: 05/16/2024
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)
Page: 2 of 3
Document Has Been Signed on 05/16/2024 07:00 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 05/16/2024 at 06:40 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: 05/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.2(b)(1)(F)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (F) The written functional capabilities assessment specified in Section 80069.2.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 5 out of 5l residents not having LIC9172 Functional Capability Assessment on file which pose health, safety and/or personal rights risks to persons in care.
POC Due Date: 05/30/2024
Plan of Correction
1
2
3
4
Administrator to complete the LIC9172 and submit self-certification by 5/30/24.
Type B
Section Cited
CCR
80072(a)(8)(E)(1)
80072 Personal Rights(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(8) Not to be placed in any restraining device. Postural supports may be used under the following conditions: (E) Under no circumstances shall postural supports include tying of, or depriving or limiting the use of, a client's hands or feet.(1) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed with prior licensing approval. Bed rails that extend the entire length of the bed are prohibited except for clients who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. 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 in R1's bed having full bed rails when doctor's order is half bed rails which poses a potential health, safety and/or personal rights risk to person in care.
POC Due Date: 05/30/2024
Plan of Correction
1
2
3
4
Corrected.
Administrator removed the other half rail.
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: 05/16/2024
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)
Page: 3 of 3