Community Care Licensing

Document Has Been Signed on 10/17/2023 05:10 PM - It Cannot Be Edited

FACILITY NAME:	BLUEGARDEN CARE		FACILITY NUMBER:	079200775
ADMINISTRATOR:	HUANG, YANLIN		FACILITY TYPE:	740
ADDRESS:	2729 MARSH DR		TELEPHONE:	(925) 208-1325
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY: 6		CENSUS: 3	DATE:	10/17/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Yanlin "Cynthia" Huang		TIME COMPLETED:	05:30 PM

SUPERVISORS NAME: Bennett Fong LICENSING EVALUATOR NAME: James Sampair LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023

Link to Parent Document Below:

FACILITY NAME: BLUEGARDEN CARE	FACILITY NUMBER: 079200775
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/17/2023

Type A

Section Cited

CCR

87303(e)(2)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. The hot water in kitchen measured at 128.7 degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2023
	Plan of Correction
1 2 3 4	Licensee shall send picture proof and/or attest to decreasing temperature to 105 to 120 degrees Fahrenheit.

Type A

Section Cited

CCR

87309(a)

(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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in the kitchen and in the main bathroom where cleaning solution was stored in unlocked kitchen and bathroom cabinets, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2023
	Plan of Correction
1 2 3 4	Licensee shall attest to LPA that the cleaners have been moved to a location inaccessible to residents.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: James Sampair LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023

Link to Parent Document Below:

FACILITY NAME: BLUEGARDEN CARE	FACILITY NUMBER: 079200775
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/17/2023

Type B

Section Cited

CCR

87208(a)

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: 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. There is no plan of operation at the facility, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/24/2023
	Plan of Correction
1 2 3 4	Licensee shall send a copy of the facility's plan of operation to the LPA.

Type B

Section Cited

CCR

87208(a)(12)

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (12) The Infection Control Plan pursuant to Section 87470. 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. There is no infection control plan at the facility, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/24/2023
	Plan of Correction
1 2 3 4	Licensee shall send a copy of the facility's infection control plan to the LPA.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: James Sampair LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023

Link to Parent Document Below:

FACILITY NAME: BLUEGARDEN CARE	FACILITY NUMBER: 079200775
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/17/2023

Type B

Section Cited

CCR

87303(e)(6)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in the main bathroom that has no toilet paper holder, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/24/2023
	Plan of Correction
1 2 3 4	Licensee shall have a toilet paper holder installed in the main bathroom and send picture proof to LPA.

Type B

Section Cited

CCR

87307(d)(5)

(5) Night lights shall be maintained in hallways and passages to nonprivate bathrooms. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. There are no nightlights in the facility's hallways, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/24/2023
	Plan of Correction
1 2 3 4	Licensee shall have night lights installed in the hallways and send picture proof to LPA.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: James Sampair LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023

Link to Parent Document Below:

FACILITY NAME: BLUEGARDEN CARE	FACILITY NUMBER: 079200775
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/17/2023

Type B

Section Cited

CCR

87412(f)

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: 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. There were no personnel records available at the facility, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/24/2023
	Plan of Correction
1 2 3 4	Licensee shall get copies of all staff records to the facility and notify LPA when they are at the facility.

Type B

Section Cited

CCR

87412(a)(13)(B)1

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). 1. For Certified Administrators, a copy their current and valid Administrative Certification meets this requirement. 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. No administrator records were available at the facility, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/24/2023
	Plan of Correction
1 2 3 4	Licensee shall get copies of all administrator records to the facility and notify LPA when they are at the facility.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: James Sampair LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023

Link to Parent Document Below:

FACILITY NAME: BLUEGARDEN CARE	FACILITY NUMBER: 079200775
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/17/2023

Type B

Section Cited

HSC

1569.625(b)(1)

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. 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. No training records were available at the facility, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/24/2023
	Plan of Correction
1 2 3 4	Licensee shall create a training plan and/or train and/or enroll all staff in the required courses for them to complete this requirement and inform LPA with proof that this has been completed.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: James Sampair LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023

Link to Parent Document Below:

FACILITY NAME: BLUEGARDEN CARE	FACILITY NUMBER: 079200775
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/17/2023

Type B

Section Cited

HSC

1569.625(b)(2)

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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. No training records were available at the facility, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/24/2023
	Plan of Correction
1 2 3 4	Licensee shall create a training plan and/or train and/or enroll all staff in the required courses for them to complete this requirement and inform LPA with proof that this has been completed.

Type B

Section Cited

CCR

87411(c)(1)

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. 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. No training records were available at the facility, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/24/2023
	Plan of Correction
1 2 3 4	Licensee shall create a training plan and/or train and/or enroll all staff in the required courses for them to complete this requirement and inform LPA with proof that this has been completed.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: James Sampair LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023

Link to Parent Document Below:

FACILITY NAME: BLUEGARDEN CARE	FACILITY NUMBER: 079200775
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/17/2023

Type B

Section Cited

CCR

87411(c)(6)

(6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer. 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. No training records were available at the facility, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/24/2023
	Plan of Correction
1 2 3 4	Licensee shall create a training plan and/or train and/or enroll all staff in the required courses for them to complete this requirement and inform LPA with proof that this has been completed.

Type B

Section Cited

HSC

1569.69(a)(4)(A)

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (4) The training shall cover all of the following areas: (A) The role, responsibilities, and limitations of staff who assist residents with the self-administration of medication, including tasks limited to licensed medical professionals. 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. No training records were available at the facility, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/24/2023
	Plan of Correction
1 2 3 4	Licensee shall create a training plan and/or train and/or enroll all staff in the required courses for them to complete this requirement and inform LPA with proof that this has been completed.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: James Sampair LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023

Link to Parent Document Below:

FACILITY NAME: BLUEGARDEN CARE	FACILITY NUMBER: 079200775
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/17/2023

Type B

Section Cited

CCR

87506(a)

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. 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. No complete resident records were available at the facility, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/24/2023
	Plan of Correction
1 2 3 4	Licensee shall create complete records for each resident of the facility and notify LPA when they are at the facility.

Type B

Section Cited

CCR

87456(a)

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: 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. No complete resident records were available at the facility, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/24/2023
	Plan of Correction
1 2 3 4	Licensee shall create complete records for each resident of the facility and notify LPA when they are at the facility.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: James Sampair LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023

Link to Parent Document Below:

FACILITY NAME: BLUEGARDEN CARE	FACILITY NUMBER: 079200775
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/17/2023

Type B

Section Cited

HSC

1569.695(a)

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: 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. No emergency and disaster plan for the facility was in use or at the facility, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/24/2023
	Plan of Correction
1 2 3 4	Licensee shall create an accurate and up-to-date emergency and disaster plan for the facility and send copy to LPA when it has been completed.

Type B

Section Cited

HSC

1569.695(a)(2)

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. An emergency supply of water or food for 72 hours immediately following an emergency or disaster does not exist at the facility, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/24/2023
	Plan of Correction
1 2 3 4	Licensee shall obtain and store an adequate supply of food and water for 72 hours immediately following an emergency or disaster and provide picture proof that it is located at the facility.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: James Sampair LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023

Link to Parent Document Below:

FACILITY NAME: BLUEGARDEN CARE	FACILITY NUMBER: 079200775
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/17/2023

Type B

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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. No emergency drill record exists at the facility, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/24/2023
	Plan of Correction
1 2 3 4	Licensee shall create a binder to record the quarterly emergency and disaster drills, conduct the first one of 2023 for every staff member, and record the results in the binder. Licensee shall send LPA copy when it has been completed.

Type B

Section Cited

HSC

1569.695(e)(1)

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (1) A resident roster with the date of birth for each resident. 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. No resident roster existed, which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/24/2023
	Plan of Correction
1 2 3 4	Licensee corrected during visit.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: James Sampair LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2023