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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200775
Report Date: 10/09/2023
Date Signed: 10/09/2023 04:51:30 PM


Document Has Been Signed on 10/09/2023 04:51 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
OAKLAND ASC, 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: 2DATE:
10/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Yanlin "Cynthia" HuangTIME COMPLETED:
05:00 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 10/09/2023 at 10:30 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced at facility for complaint investigation and added the required annual inspection when complaint investigation completed. Upon entry, LPA informed Caregiver Evelia Galvan of the purpose of the visit, who informed Administrator (ADM) Yanlin "Cynthia" Huang. ADM arrived at approximately 11:15 AM.

During the visit, LPA reviewed facility and resident records, and interviewed 1 resident, 1 staff member, and ADM.

1 Type-A citation issued during the inspection (details in LIC809-D) and Civil Penalty of $200 (details in LIC421-BG).

Annual inspection incomplete. LPA will return unannounced to complete the inspection.

Exit interview conducted with Licensee and a copy of this report was provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023
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 2


Document Has Been Signed on 10/09/2023 04:51 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: BLUEGARDEN CARE
FACILITY NUMBER: 079200775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

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 2 out of 3 caregivers, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2023
Plan of Correction
1
2
3
4
Caregivers left facility during inspection and cleared deficiency.
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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2