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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200825
Report Date: 09/04/2024
Date Signed: 09/04/2024 03:39:29 PM


Document Has Been Signed on 09/04/2024 03:39 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:BLUEMEADOW CAREFACILITY NUMBER:
079200825
ADMINISTRATOR:HUANG, YANLINFACILITY TYPE:
740
ADDRESS:3262 MONTEVIDEO DRTELEPHONE:
(925) 833-2677
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:6CENSUS: 6DATE:
09/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Licensee, Yanlin "Cynthia" HuangTIME COMPLETED:
03:50 PM
NARRATIVE
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On 09/04/2024 at 9:20 AM, Licensing Program Analysts (LPAs) A. Gomez and P Manalo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Licensee, Yanlin "Cynthia" Huang and explained the purpose of the visit. The facility’s fire clearance was approved for 6 non-ambulatory of which one may be bedridden in room 6.

LPA toured facility with Licensee including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 103.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is not a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were not locked and inaccessible to residents.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was not inspected and did not have a receipt of purchase. Emergency Disaster Plan was last posted on 9/04/2024. First aid kit was observed to be complete. Emergency disaster drills were not available.

LPA reviewed 6 residents records. LPAs reviewed 3 staff records. LPA reviewed a sample of resident’s medications.

Report Continues on LIC809-C
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BLUEMEADOW CARE
FACILITY NUMBER: 079200825
VISIT DATE: 09/04/2024
NARRATIVE
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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:
  • Upon arrival LPAs were greeted by a "caregiver" who was later identified as David Last name Unknown. The individual vacated the property without the LPA's knowledge. Licensee informed LPAs that the individual is not eligible to be cleared. Licensee states that they have no other information for the individual.
  • At 9:29AM LPAs observed unlocked vitamins and over the counter medications available in Licensee's room with the door open and the Licensee in the shower.
  • At 9:30AM LPAs observed a black butcher knife unsupervised on a red cutting board.
  • At 9:30AM LPAs observed unsupervised resident medications on the kitchen counter
  • At 9:31AM LPAs observed the sliding screen door to be ripped and in disrepair. Later LPAs observed screen on residents window with a large rip on the upper right corner that appeared to have been previously taped up
  • At 9:36AM LPAs observed medication closet unlocked and accessible
  • At 11:20AM LPAs saw on camera footage that S2 sleeps at night in the common area on the sofa next to the front door.
  • At 12:00PM LPAs observed R1's, R2's physician report is expired
  • At 12:10 PM LPAs observed the water temperature at 103.5.
  • At 12:24PM LPA's observed R4, R5, and R6 to have incomplete files
  • At 1:12 PM LPA's observed that S2 and S3 was not updated on training's. Staff files were also incomplete.
  • At 1:12 PM LPA's observed that S3 does not have a first aid on file.
  • At 2:30PM LPAs observed that the facility did not have enough food.
  • Throughout visit LPAs observed that the facility did not have stimulating activities available to residents


*** A civil penalty is being assessed in the amount of $500***

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code 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.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/04/2024 03:39 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: BLUEMEADOW CARE
FACILITY NUMBER: 079200825

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2024

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
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Based on observation, the licensee did not comply with the section cited above inhaving a knife accesable to residents which poses an immediate safety risk to persons in care.
POC Due Date: 09/04/2024
Plan of Correction
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Staff put knife away
Type A
Section Cited
CCR
87355(e)(1)
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance …

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in having an unidentified uncleared individual working which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 09/04/2024
Plan of Correction
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Individual left during visit. Civil Penalty Assesed
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: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: BLUEMEADOW CARE
FACILITY NUMBER: 079200825

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having screens ripped which poses a potential personal rights risk to persons in care.
POC Due Date: 09/25/2024
Plan of Correction
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By POC Licensee agrees to repair or replace screens and notify CCLD.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not having complete staff files which poses a potential personal rights risk to persons in care.
POC Due Date: 09/25/2024
Plan of Correction
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By POC Licensee agrees to review and update staff files and notify CCLD.
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: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: BLUEMEADOW CARE
FACILITY NUMBER: 079200825

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not having staff up to date on trainings which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 09/25/2024
Plan of Correction
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By POC Licensee agrees to provide trainings and record the competions and notify CCLD.
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not having all required staff first aid trained which poses a potential health, and safety risk to persons in care.
POC Due Date: 09/25/2024
Plan of Correction
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By POC Licensee agrees to provide trainings and record the competions and notify CCLD.
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: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/04/2024 03:39 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: BLUEMEADOW CARE
FACILITY NUMBER: 079200825

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(1)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities shall be posted as applicable to the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation], the licensee did not comply with the section cited above in not having the required information posted which poses a potential personal rights risk to persons in care.
POC Due Date: 09/25/2024
Plan of Correction
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By POC date Licensee agrees to post required information and notify CCLD.
Type B
Section Cited
CCR
87307(a)
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for… staff…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having S2 sleep in the living room at night which poses a potential personal rights risk to persons in care.
POC Due Date: 09/05/2024
Plan of Correction
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By POC Licensee agrees to no longer allow staff to sleep in common areas.
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: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: BLUEMEADOW CARE
FACILITY NUMBER: 079200825

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in not having the required sign posted which poses a potential personal rights risk to persons in care.
POC Due Date: 09/25/2024
Plan of Correction
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By POC date Licensee agrees to post the required signs and notify CCLD

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: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: BLUEMEADOW CARE
FACILITY NUMBER: 079200825

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(a)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in not having scheduled activities which poses a potential personal rights risk to persons in care.
POC Due Date: 09/25/2024
Plan of Correction
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2
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4
By POC date Licensee agrees to develop and implement an activities schedule and notify CCLD
Type B
Section Cited
CCR
87555(a)
General Food Service Requirements
(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.

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 in not having enough food available which poses a potential personal rights risk to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
1
2
3
4
By POC date Licensee agrees to purchase adequate food and notify CCLD.
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: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: BLUEMEADOW CARE
FACILITY NUMBER: 079200825

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)
Resident Records
(b) Each resident's record shall contain at least the following 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 in residents records being incomplete which poses a potential personal rights risk to persons in care.
POC Due Date: 09/25/2024
Plan of Correction
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2
3
4
By POC date Licensee agrees to review all clients files and update and notify CCLD
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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 in not having record of disaster drills which poses a potential safety risk to persons in care.
POC Due Date: 09/25/2024
Plan of Correction
1
2
3
4
By POC date Licensee agrees to conduct and document drills and notify CCLD
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: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: BLUEMEADOW CARE
FACILITY NUMBER: 079200825

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
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 annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

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 in clients not having an up to date medical which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/25/2024
Plan of Correction
1
2
3
4
By POC date Licensee agrees to review all clients files and update and notify CCLD
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: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/04/2024 03:39 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: BLUEMEADOW CARE
FACILITY NUMBER: 079200825

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2)Faucets used by residents for personal care ...attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

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 in hot water temprature not measuring in range which poses a potential health and, personal rights risk to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
1
2
3
4
By POC Licensee agrees to adjust water and notify CCLD.
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: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
LIC809 (FAS) - (06/04)
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