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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200775
Report Date: 05/20/2022
Date Signed: 05/20/2022 04:56:36 PM


Document Has Been Signed on 05/20/2022 04:56 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:BLUEGARDEN CAREFACILITY NUMBER:
079200775
ADMINISTRATOR:HUANG, YANLINFACILITY TYPE:
740
ADDRESS:2729 MARSH DRTELEPHONE:
(925) 208-1325
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:6CENSUS: DATE:
05/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Yanlin "Cynthia" Huang, AdministratorTIME COMPLETED:
05:15 PM
NARRATIVE
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On 5/20/2022 at 2:35 PM, Licensing Program Analyst (LPAs) L. Francisco and K. Nguyeb arrived unannounced to conduct Infection Control Inspection. LPAs met with Administrator, Yanlin "Cynthia" Huang and explained the purpose of the visit.

During the Infection Control Inspection, LPA toured facility with Admnistrator including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, paper towel and trash bin with touchless lids. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

THE FOLLOWING DEFICIENCIES WERE OBSERVED:
  • At 2:38 PM, LPAs were not screened at the front main entrance
  • At 2:45 PM, LPAs observed medication cabinet unlocked in the garage
  • At 2:51 PM, LPAs observed unlocked knives inside kitchen cabinet.
  • At 2:53 PM, LPAs observed unlocked medication inside the kitchen island drawer
  • At approximate;y 2:55 PM, LPAs observed two visitors were not screened and temperature was not checked
  • At 2:58 PM, LPAs observed Lysol and Fabuloso inside the centrally stored medication closet
  • At: 3:30 PM, Personnel records are not being maintained at facility
  • At 3:35 PM, LPAs observed a special vistor was not screened and temperature was not taken

REPORT CONTINUES ON 809C
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
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: BLUEGARDEN CARE
FACILITY NUMBER: 079200775
VISIT DATE: 05/20/2022
NARRATIVE
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 5/27/2022:
  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan
  • Liability Insurance
  • Current Administrator’s Certificate

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 05/20/2022 04:56 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: BLUEGARDEN CARE
FACILITY NUMBER: 079200775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which 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. LPAs observed cleaning supplies cabinet in garage was unlocked which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/21/2022
Plan of Correction
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Deficiency cleared during visit. LPAs observed Administrator locked cleaning supplies cabinet.

In addition, Administrator will review regulation and conduct in-service training with staff and submit a copy of training agenda with staff signature to CCLD by 5/27/2022.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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. LPAs observed unlocked medication inside kitchen drawer which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/21/2022
Plan of Correction
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Deficiency cleared during visit. LPAs observed Administrator locked knives away.

In addition, Administrator will review regulation and conduct in-service training with staff and submit a copy of training agenda with staff signature to CCLD by 5/27/2022.

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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
LIC809 (FAS) - (06/04)
Page: 3 of 9


Document Has Been Signed on 05/20/2022 04:56 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: BLUEGARDEN CARE
FACILITY NUMBER: 079200775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

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. LPAs observed unlocked knives inside kitchen cabinet which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/21/2022
Plan of Correction
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Deficiency cleared during visit. LPAs observed Administrator locked knives away.

In addition, Administrator will review regulation and conduct in-service training with staff and submit a copy of training agenda with staff signature to CCLD by 5/27/2022.
Type A
Section Cited
CCR
87309(b)
87309 STORAGE SPACE
(b) Medicines which are centrally stored shall be stored as specified in Section 87465 and separately from other items specified in (a) above.


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. LPAs observed disinfectant and cleaning supply stored inside centrally stored medication closet which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/21/2022
Plan of Correction
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Deficiency cleared during visit. LPAs observed Administrator removed items and locked it away.

In addition, Administrator will review regulation and conduct in-service training with staff and submit a copy of training agenda with staff signature to CCLD by 5/27/2022.

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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
LIC809 (FAS) - (06/04)
Page: 4 of 9


Document Has Been Signed on 05/20/2022 04:56 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: BLUEGARDEN CARE
FACILITY NUMBER: 079200775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

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. LPAs were unable to review staff records because records are not being maintained at facility which poses a potential health and safety risk to persons in care.
POC Due Date: 05/24/2022
Plan of Correction
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Administrator will review regulation and maintain personnel records at facility. Administrator will submit self-certification letter to CCL by POC date.
Type B
Section Cited
CCR
87465(d)(2)
87405 Administrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations.

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. LPAs observed visitors are not being properly screened and staff are not wearing masks which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2022
Plan of Correction
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Administrator will review local county health order and Providers Information Notification from CCLD website. Administrator will implement guidance and submit self-certification letter to CCL.

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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
LIC809 (FAS) - (06/04)
Page: 5 of 9