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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200825
Report Date: 01/12/2023
Date Signed: 01/12/2023 01:00:34 PM


Document Has Been Signed on 01/12/2023 01:00 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:BLUEMEADOW CAREFACILITY NUMBER:
079200825
ADMINISTRATOR:HUANG, YANLINFACILITY TYPE:
740
ADDRESS:3262 MONTEVIDEO DRTELEPHONE:
(925) 833-2677
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:6CENSUS: 4DATE:
01/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Yanlin "Cynthia" HuangTIME COMPLETED:
01:20 PM
NARRATIVE
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On 1/12/2023 at 11:40 AM, Licensing Program Analysts (LPAs) L. Francisco and C. Lin conducted a Case Management (CM) and met with Administrator, Yanlin "Cynthia" Huang . LPAs explained to Administrator that this CM is being conducted in connection with a complaint investigated by the Department.

During the course of investigation, the Department observed R1 fell off the wheelchair and sustained a cut on the chin in April 2020. On May 28, 2020, R1 was observed with bleeding eyes. The facility failed to send incident reports to CCL.

While at the facility on 1/12/2023, LPAs observed the following deficiencies:

-At 9:58 AM, LPAs observed R4 does not have an updated appraisal plan on file.
-At 10:35 AM, LPAs observed laundry detergent on top of the dryer inside the unlocked laundry room.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided to Administrator.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023
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 3


Document Has Been Signed on 01/12/2023 01:00 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: BLUEMEADOW CARE
FACILITY NUMBER: 079200825

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/19/2023
Section Cited

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87705(f)(2) CARE OF PERSONS WITH DEMENTIA
(f)The following shall be stored inaccessible to residents with dementia:(2)...and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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By POC date, Licensee will review regulation and conduct in-service training with all staff and submit a copy of training with staff signatures to CCL.
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This requirement is not met as evidenced by: Based on observation, Licensee did not comply with regulation cited above. LPAs observed unlocked cleaning supplies in unlocked laundry room which poses an immediate health and safety risk to persons in care.
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Type B
01/19/2023
Section Cited

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87411(a)(1)(D) REPORT REQUIREMENTS
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the…(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any residents.
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By POC date, Administrator will review Sec 87211 Reporting Requirements and submit self-certification of understanding to CCL
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This requirement is not met as evidenced by: Based on record review, Licensee did not comply with the regulation cited above. Facility did not submit incident reports for when R1 fell off the wheelchair and sustained a cut on the chin in April 2020. In addition on May 28, 2020 where R1 was observed with bleeding eyes which poses a potential health and safety risk to persons in care.
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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: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 01/12/2023 01:00 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: BLUEMEADOW CARE
FACILITY NUMBER: 079200825

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2023
Section Cited

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87705(c)(5) CARE OF PERSONS WITH DEMENTIA
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an .... and a reappraisal done at least annually...
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By POC date, Administrator agrees to update R4's appraisal and submit a copy to CCL.
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This requirement is not met as evidenced by: Based on record review, Licensee did not comply with the regulation cited above. LPAs observed R4 does not have an updated appraisal on file which poses a potential health and safety risk to persons in care.
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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: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023
LIC809 (FAS) - (06/04)
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