015601482-12-7-2023-15-AS-ADEO-CYB5H7-20231207185752

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601482
Report Date: 12/07/2023
Date Signed: 12/07/2023 06:57:59 PM

Document Has Been Signed on 12/07/2023 06:57 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:	BLOSSOM GARDEN SENIOR HOME		FACILITY NUMBER:	015601482
ADMINISTRATOR:	HYESUS, FEKERTE		FACILITY TYPE:	740
ADDRESS:	21307 WESTERN BLVD		TELEPHONE:	(510) 363-8566
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	9	CENSUS: 8	DATE:	12/07/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Fekerte Hyesus/Administrator		TIME COMPLETED:	07:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On this day, December 7, 2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Fekerte Hyesus, administrator, and informed the reason for visit. LPA also met with other staff, Avelina Sagnep. Administrator submitted the facility's Infection Control Plan which LPA received on November 11, 2022. LPA toured the facility inside out with the administrator. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, side yard and backyard. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked. Facility has smoke and carbon monoxide detectors that were tested, and observed functional. Facility conducts disaster drills quarterly, and records showed last conducted September 15, 2023. Fire extinguishers checked, observed fully charge with tags showed serviced May 25, 2023. LPA reviewed 4 staff and 5 residents files, and interviewed 2 staff and 2 residents. Medications checked, and compared with records and doctor's orders. Facility does not handle residents' cash resources. LPA received the following updated/current documents: 1. LIC500 Personnel Report 2. LIC610E Emergency Disaster Plan (9 pages) .....continued on 809C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BLOSSOM GARDEN SENIOR HOME	FACILITY NUMBER: 015601482
	VISIT DATE: 12/07/2023

NARRATIVE

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Administrator to submit copies the following by December 21, 2023:
1. $3M Liability Insurance certificate
2. LIC308 Designation of Facility Responsibility

The following deficiencies were observed and cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties.

-at 12:30 pm, knives in kitchen cabinets without lock.
-at 12:33 pm, bleach, cleaning agents, and Comet cleanser in the Alarm Panel room without lock
-at 2:00 pm, administrator's First Aid certificate expired 11/24/23.
-at 2:10 pm and 2:25 pm, S2 and S3 have no LIC503 Health Screening on file.
-at 2:35 pm, S4 who got hired 7/2023 has only 21 hours training on file.

Deficiencies and plan and proof of corrections were discussed with the administrator.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/07/2023 06:57 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: BLOSSOM GARDEN SENIOR HOME	FACILITY NUMBER: 015601482
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/07/2023

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above for the following which pose an immediate health, safety and/or personal rights risk to persons in care: knives in the kitchen cabinets without lock; bleach, cleaning agents, and Comet cleanser in the Alarm Panel room without lock
	POC Due Date: 12/08/2023
	Plan of Correction
1 2 3 4	Administor locked all the items. In addition, administrator to in-service the staff and submit training topic with attendees signatures by 12/08/23.

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: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/07/2023 06:57 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: BLOSSOM GARDEN SENIOR HOME	FACILITY NUMBER: 015601482
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above for administrator's first aid certificate expired which poses a potential safety and/or personal rights risk to persons in care.
	POC Due Date: 12/21/2023
	Plan of Correction
1 2 3 4	Administrator to complete the training and submit copy of the certificate by 12/21/23.

Type B

Section Cited

CCR

87411(f)

87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition..... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section in 3 out of 4 staff not having LIC503 Health Screening on file which pose a potential health and/or personal rights risk to persons in care.
	POC Due Date: 12/21/2023
	Plan of Correction
1 2 3 4	Administrator to have the staff undergo Health Screening and submit copies of LIC503s by 12/21/23.

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) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 12/07/2023 06:58 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: BLOSSOM GARDEN SENIOR HOME	FACILITY NUMBER: 015601482
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

1569.625

§1569.625 Staff training; legislative findings; contents (b)(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. . 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. S4 has only total of 21 hours training on file which poses a potential health, safety and/or personal rights risk to persons in care.
	POC Due Date: 12/21/2023
	Plan of Correction
1 2 3 4	Administrator to have the staff complete the traning and submit self-certification by 12/21/23.

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) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023

LIC809 (FAS) - (06/04)

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