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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200825
Report Date: 01/12/2023
Date Signed: 01/12/2023 12:53:45 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
01/19/2021 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210119151543
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
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Yanlin "Cynthia" Huang, AdministratorTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Resident developed a pressure injury requiring hospitalization
Resident had an unexplained injury
INVESTIGATION FINDINGS:
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On 1/12/2023 starting at 9:30 AM, Licensing Program Analysts (LPAs) L. Francisco and C. Lin arrived unannounced to deliver findings for the above allegations. LPAs met with Administrator, Yanlin “Cynthia” Huang and explained the purpose of the visit.

During the course of investigation, the Department conducted interviews with facility staff, witnesses and complainant and reviewed records. Documents including but not limited to: Resident 1 (R1) needs and services plan, physician’s report, care plan, incident reports, photos of resident, discharge notes, and home health notes were obtained.


REPORT CONTINUED ON 9099C
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 15-AS-20210119151543
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: BLUEMEADOW CARE
FACILITY NUMBER: 079200825
VISIT DATE: 01/12/2023
NARRATIVE
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The Department investigated resident developed a pressure injury requiring hospitalization. Based on record review, R1 was admitted to the facility on June of 2015 under the prior License. Sometime in April 2020, R1’s right heel bumped on the wheelchair. On 4/8/2020, R1’s wound was diagnosed unstageable by attending physician at John Muir Hospital and wound care was initiated. The same day, home health nurse instructed facility staff to supervise R1 at all times, to off-load pressure to right heel at all times, feed R1 with high protein diet and to reposition every two hours. On 5/18/2020 and 6/5/2020, Home Health Nurse observed R1’s wound pressed against the bed despite instructions to off-load and elevate the heel with pillows. On 6/9/2020, R1 was admitted to Emergency Department and the pressure injury was diagnosed at Stage 4. Bone was exposed and 60% of the heel was necrotic tissue. Test results revealed R1 had Osteomyelitis due to bacterial infection which infected R1’s bloodstream.

The Department investigated resident had an unexplained injury. On 5/28/2020, facility staff informed home health nurse that R1 had fallen from the wheelchair earlier in the day and sustained a skin tear to the chin when R1 leaned over in the wheelchair to pick up something. On 6/9/2020, caregiver advised R1’s left eye had been bleeding for the past two days but could not explain why or how R1 sustained the injury. Upon R1’s admission to the Emergency Department on 6/9/2020, R1 was diagnosed with bilateral conjunctivitis.

Based on the Department’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) and Health and Safety Code are being cited on the attached LIC 9099D.

A $500 Civil Penalty is being assessed. Civil penalty determination related to serious bodily injury is pending.

Exit interview conducted. Appeal rights and a copy of this report was 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
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
01/19/2021 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210119151543

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
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Yanlin "Cynthia" Huang, AdministratorTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Residents needs are not being met due to insufficient staffing
Resident not afforded dignity while in care
INVESTIGATION FINDINGS:
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On 1/12/2023 starting at 9:30 AM, Licensing Program Analysts (LPAs) L. Francisco and C. Lin arrived unannounced to deliver findings for the above allegations. LPAs met with Administrator, Yanlin “Cynthia” Huang and explained the purpose of the visit.

During the course of investigation, the Department conducted interviews with facility staff, complainant and reviewed records. Documents including but not limited to: Resident 1 (R1) needs and services plan, physician’s report, care plan, incident reports, photos of resident, discharge notes, and home health notes were obtained.

REPORT CONTINUED ON 9099C
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 15-AS-20210119151543
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: BLUEMEADOW CARE
FACILITY NUMBER: 079200825
VISIT DATE: 01/12/2023
NARRATIVE
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The Department investigated residents needs are not being met due to insufficient staffing. Based on interview with 3 staff and 3 residents, 3 of 3 staff and 3 of 3 residents stated that there are no issues with staffing.

The Department investigated resident not afforded dignity while in care. Based on interview with 3 residents, 2 of 3 residents stated they are provided with privacy. During an interview with 3 staff, 3 of 3 staff stated they close the door when they are changing the residents and assisting residents in the bathroom.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation are UNSUBSTANTIATED.

Exit interview conducted with Administrator and a copy of this report provided.
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
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
01/19/2021 and conducted by Evaluator Lizette Francisco
COMPLAINT CONTROL NUMBER: 15-AS-20210119151543

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
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Yanlin "Cynthia" Huang, AdministratorTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Staff did not notify authorized representative of resident's change of condition
INVESTIGATION FINDINGS:
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On 1/12/2023 starting at 9:30 AM, Licensing Program Analysts (LPAs) L. Francisco and C. Lin arrived unannounced to deliver findings for the above allegations. LPAs met with Administrator, Yanlin “Cynthia” Huang and explained the purpose of the visit.

Based on the Department’s investigation, facility contacted R1’s Power of Attorney (POA) on multiple occasions via telephone and text message. However, R1’s POA rarely returned the facility’s calls so facility contacted the secondary POA. R1’s secondary POA confirmed with investigator facility has contacted secondary POA for various reasons.

REPORT CONTINUED ON 9099C
Unfounded
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 15-AS-20210119151543
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: BLUEMEADOW CARE
FACILITY NUMBER: 079200825
VISIT DATE: 01/12/2023
NARRATIVE
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Based on documents reviewed, facility contacted home health nurses regarding R1’s health status.
This agency has investigated the complaint alleging staff did not notify resident’s authorized representative of resident’s change in condition. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.

There is no deficiency noted.

Exit interview was conducted with Administrator and a copy of this report was provided.
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
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 15-AS-20210119151543
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: 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
01/13/2023
Section Cited
HSC
1569.269(a)(10)
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1569.269(a)(10) ENUMERATED RIGHTS; SEVERABILITY
(a) Residents of residential care facilities for the elderly shall have all of the following rights: (10)To be free from neglect...

This requirement is not met as evidenced by:
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By POC date, Administrator will conduct training with staff on the Health and Safety Code 1569.269 Enumerated Rights; severability and submit proof of training with staff signatures to CCL by 1/13/2023
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Based on the Department’s interviews and record review, Licensee did not comply with the regulation cited above. In April 2020, Home Health nurse instructed staff to off-load pressure to R1’s right heel at all times and to reposition every 2 hours. Nurse observed R1’s wound pressed against the bed twice. On 6/9/2020, R1 was admitted to hospital and pressure injury was diagnosed at Stage 4. Bone was exposed and test results revealed R1 had Osteomyelitis due to bacterial infection which infected R1’s bloodstream.
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A Non-Compliance Conference (NCC) will be scheduled.

A $500 Civil Penalty is being assessed. Civil penalty determination related to serious bodily injury is pending.
Type A
01/13/2023
Section Cited
CCR
87466
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87466 OBSERVATION OF THE RESIDENT
The licensee shall ensure that residents are regularly observed for changes in physical......changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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By POC date, Administrator and staff will review Sec 87466 Observation of Resident and submit proof to CCL by 1/13/2023
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This requirement is not met as evidenced by: Based on the Department’s interviews and record review, Licensee did not comply with the regulation cited above. Facility staff were instructed by Home Health nurse to supervise R1 at all times. On 5/28/2020, R1 fell off the wheelchair which resulted to R1 sustaining a cut on the chin. On 6/9/2020, staff informed Home Health nurse that R1’s eyes have been bleeding for two days. R1’s primary doctor was not notified.
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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
LIC9099 (FAS) - (06/04)
Page: 7 of 7