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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200775
Report Date: 10/30/2023
Date Signed: 10/30/2023 01:38:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/23/2023 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20231023113701
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:
10/30/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Cynthia Huang, AdministratorTIME COMPLETED:
01:55 PM
ALLEGATION(S):
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Facility did not provide a copy of resident's admission agreement to resident's authorized representative
INVESTIGATION FINDINGS:
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On 10/30/2023 at 11:15AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with caregiver, Carleen Sablan and informed her the reason for visit. Administrator, Cynthia Huang arrived 45 minutes later.

During the course of investigation, LPA interviewed 2 residents and 2 staff. LPA obtained and reviewed R1's admission agreement. Interview with staff revealed that a copy of the admission agreement was not given to resident/authorized representative because they did not request for a copy.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC 9099D. Exit interview conducted. A copy of this report and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20231023113701
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/10/2023
Section Cited
CCR
87507(e)
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Admission Agreements. The licensee shall provide a copy of the signed ...admission agreement ...immediately upon signing the admission agreement... This requirement is not met as evidence by:
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Administrator has agreed to provide a copy of the admission agreement to resident and review regulation regarding admission agreement.
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Based on investigation, licensee did not comply with the section cited above by not providing a copy of the admission agreement to resident which poses a potential health and safety risk to the persons in care.
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Administrator will submit self-certification by POC date.
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/23/2023 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20231023113701

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:
10/30/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Cynthia Huang, AdministratorTIME COMPLETED:
01:55 PM
ALLEGATION(S):
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3
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9
Facility did not issue a full refund to resident's authorized representative
INVESTIGATION FINDINGS:
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On 10/30/2023 at 11:15AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPA met with caregiver, Carleen Sablan and informed her the reason for visit. Administrator, Cynthia Huang arrived 45 minutes later.

During the course of investigation, LPA interviewed 2 residents and 2 staff. LPA obtained and reviewed R1's admission agreement and picture of refund check. LPA observed R1's admission agreement states that first payment (first month) is non-refundable. Interview with staff revealed a refund of $2500 was given to R1's authorized representative.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted. A copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3