079200825-4-4-2023-15-AS-KHOS-CRLPJZ-20230507112221

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200825
Report Date: 04/04/2023
Date Signed: 04/04/2023 12:18:30 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
03/28/2023 and conducted by Evaluator Carol Fowler

COMPLAINT CONTROL NUMBER: 15-AS-20230328172856

FACILITY NAME:	BLUEMEADOW CARE		FACILITY NUMBER:	079200825
ADMINISTRATOR:	HUANG, YANLIN		FACILITY TYPE:	740
ADDRESS:	3262 MONTEVIDEO DR		TELEPHONE:	(925) 833-2677
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	6	CENSUS: 5	DATE:	04/04/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	YANLIN HUANG, ADMINISTRATOR		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility not properly storing medications.

INVESTIGATION FINDINGS:

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On 4/04/2023 at 9:45AM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct complaint investigation for the above allegation. LPA met with Administrator Yanlin "Cynthia" Huang and explained the purpose of the visit.

During the complaint investigation, LPA conducted a tour of the medication closet and interview with S1. LPA observed 3 to 5 days of pre-poured medication transferred into a weekly pill organizer for all 5 residents. S1 stated that S1 pre-poured /transfered the medication in the weekly pill organizer for all 5 residents.

Based on LPAs observations and interview, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230328172856

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: 04/04/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/11/2023 Section Cited CCR 87465(h)(5)	1 2 3 4 5 6 7	(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Licensee/Administrator will submit a written statement of having read and understood the regulation and conducted in-service training with all staff, providing CCLD with a copy of all signatures of staff attended no later than the POC date.
	8 9 10 11 12 13 14	Based on LPA's observation licensee did not coply with the section cited above by having medication transferred into a weekly pill organizer which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

LIC9099 (FAS) - (06/04)

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