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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200775
Report Date: 03/22/2024
Date Signed: 03/22/2024 12:10:12 PM


Document Has Been Signed on 03/22/2024 12:10 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: DATE:
03/22/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Caregiver, Carline Skang TIME COMPLETED:
12:15 PM
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On 03/22/2024 at 10:05am, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct proof of correction (POC) visit. LPA met with Carline Skang,Caregiver and explained the purpose of the visit. Administrator was notified of visit and approved caregiver to sign off on report.

LPA A Gomez conducted an Annual visit on 03/12/2024 and cited facility for the following:

  • 87412(a): During POC visit LPA reviewed the files for caregivers on shift. Staff (S1) file was observed to be incomplete and missing the LIC 508, LIC 501, and First Aid (Deficiency not clear)
  • 87506(a): During POC visit LPA reviewed the files for residents and resident (R1) file was observed to be incomplete and missing signed and completed copies of the LIC 601, LIC 613C, LIC 627, and LIC 625 (Deficiency not clear)


LPA spoke with administrator over the phone who stated that they need more time to obtain signatures for R1's records due to the family being unavailable. LPA also spoke to the administrator about S1 not having a complete file available at the facility for review to which the administrator requested more time. The LPA agreed to give the administrator a 2 week extension to clear the deficiencies and will return at a later date. The above POC's due date is now 4/5/2024

LPA observed that deficiency are not clear. No civil penalties assessed at this time

Exit interview conducted and a copy of this report provided

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024
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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