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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
079200775
Report Date:
10/31/2023
Date Signed:
10/31/2023 06:02:37 PM
Document Has Been Signed on
10/31/2023 06:02 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 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:
2
DATE:
10/31/2023
TYPE OF VISIT:
Case Management - Annual Continuation
UNANNOUNCED
TIME BEGAN:
09:25 AM
MET WITH:
Yanlin "Cynthia" Huang
TIME COMPLETED:
06:15 PM
NARRATIVE
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On 10/31/2023 at 9:25 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced for an annual inspection continuation visit. Upon entry into the facility, LPA explained the purpose of the visit to Caregivers Carleen Sablan and Carline Skang. Licensee Yanlin "Cynthia" Huang arrived at approximately 10:00 AM.
During the Inspection, the LPA reviewed facility records.
1 Type-A and 5 Type-B citations issued (for details refer to LIC809-D).
Annual inspection incomplete. LPA will return unannounced at a future date and time.
Exit interview conducted with Licensee. A copy of the Appeal Rights and this report provided to Licensee via email.
SUPERVISORS NAME
:
Bennett Fong
LICENSING EVALUATOR NAME
:
James Sampair
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/31/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/31/2023
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
5
Document Has Been Signed on
10/31/2023 06:02 PM
- It Cannot Be Edited
Created By:
James Sampair
On
10/31/2023
at
04:28 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:
BLUEGARDEN CARE
FACILITY NUMBER:
079200775
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/31/2023
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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. A pair of scissors was in unlocked drawer in kitchen, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
11/01/2023
Plan of Correction
1
2
3
4
Licensee cleared violation during visit.
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 Fong
LICENSING EVALUATOR NAME:
James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE:
10/31/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/31/2023
LIC809
(FAS) - (06/04)
Page:
2
of
5
Document Has Been Signed on
10/31/2023 06:02 PM
- It Cannot Be Edited
Created By:
James Sampair
On
10/31/2023
at
04:28 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:
BLUEGARDEN CARE
FACILITY NUMBER:
079200775
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/31/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do 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, because 0 of 2 staff members who are on duty have cardiopulmonary resuscitation (CPR) training or first aid training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/07/2023
Plan of Correction
1
2
3
4
Staff members shall complete their training in CPR and first aid. Licensee shall inform LPA that they have completed their training.
Type B
Section Cited
CCR
87415(a)
Night Supervision
(a) The following persons providing night supervision from 10:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services, and shall be available as indicated below to assist in caring for residents in the event of an emergency:
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, because 0 of 2 staff members who are on duty have cardiopulmonary resuscitation (CPR) training or first aid training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/07/2023
Plan of Correction
1
2
3
4
Staff members shall complete their training in CPR and first aid. Licensee shall inform LPA that they have completed their training.
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:
James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE:
10/31/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/31/2023
LIC809
(FAS) - (06/04)
Page:
3
of
5
Document Has Been Signed on
10/31/2023 06:02 PM
- It Cannot Be Edited
Created By:
James Sampair
On
10/31/2023
at
04:28 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:
BLUEGARDEN CARE
FACILITY NUMBER:
079200775
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/31/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(e)(2)
Admission Agreements
(2) The licensee shall conspicuously post in a location accessible to public view in the facility a complete copy of the approved admission agreement, modifications and attachments, or notice of their availability from the facility.
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, because no Admission Agreement is posted at the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/07/2023
Plan of Correction
1
2
3
4
Licensee shall post copy of Admission Agreement. Licensee shall inform LPA when posted.
Type B
Section Cited
CCR
87508(b)
Register of Residents
(a) The licensee shall ensure that a current register of all residents in the facility is maintained and contains the following updated information:
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, because she has no register of current residents, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/07/2023
Plan of Correction
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2
3
4
Licensee shall create current register of all residents in the facility. Licensee shall inform LPA when register created.
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:
James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE:
10/31/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/31/2023
LIC809
(FAS) - (06/04)
Page:
4
of
5
Document Has Been Signed on
10/31/2023 06:02 PM
- It Cannot Be Edited
Created By:
James Sampair
On
10/31/2023
at
04:28 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:
BLUEGARDEN CARE
FACILITY NUMBER:
079200775
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/31/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Resident's Bill of Rights
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Type B
Section Cited
CCR
87465(a)(8)
Incidental Medical and Dental Care Services
(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following:
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, because there is not a current first aid kit at the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/07/2023
Plan of Correction
1
2
3
4
Cleared during inspection.
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:
James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE:
10/31/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/31/2023
LIC809
(FAS) - (06/04)
Page:
5
of
5