Community Care Licensing

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Lizette Francisco TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2023

Document Has Been Signed on 03/24/2023 06:11 PM - It Cannot Be Edited

FACILITY NAME: BLUEMEADOW CARE	FACILITY NUMBER: 079200825
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/24/2023

Type A

Section Cited

CCR

87202(a)

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above. LPA observed garage is being utilized as a sleeping area for staff overnight which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/25/2023
	Plan of Correction
1 2 3 4	By POC date, Administator will either submit LIC 200 with floor sketch or submit a proof of photo that garage is no long being used as a sleeping area. An immediate $500 Civil Penalty is being assessed

Type A

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 such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees 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 by maintaing hot water in shared resident's bathroom at 141 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/25/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator will lower the temperature between 105 degrees F - 120 degrees F and submit photo to CCLD.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Lizette Francisco TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2023

Document Has Been Signed on 03/24/2023 06:11 PM - It Cannot Be Edited

FACILITY NAME: BLUEMEADOW CARE	FACILITY NUMBER: 079200825
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/24/2023

Type A

Section Cited

CCR

87303(e)(3)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. 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 by. Based observation, hot water is maintained at 141 degrees F and no warning sign was posted which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Deficiency cleared during visit. Administrator posted a warning sign in resident's shared bathroom.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Lizette Francisco TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2023

Document Has Been Signed on 03/24/2023 06:11 PM - It Cannot Be Edited

FACILITY NAME: BLUEMEADOW CARE	FACILITY NUMBER: 079200825
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/24/2023

Type B

Section Cited

CCR

87411(f)

(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 that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 by not obtaining a health screening and TB test for S1 and S2 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator will obtain health screening and TB test for S1 and S2 and submit a copy to CCLD.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Lizette Francisco TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2023

Document Has Been Signed on 03/24/2023 06:11 PM - It Cannot Be Edited

FACILITY NAME: BLUEMEADOW CARE	FACILITY NUMBER: 079200825
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/24/2023

Type B

Section Cited

HSC

1569.618(c)(3)

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. 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 by not having a staff for each shift with CPR training which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator agrees to obtain a CPR training for all staff and submit a copy of CPR certificate to CCLD

Type B

Section Cited

CCR

87415(a)

(a) The following persons providing night supervision from 10:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services, and shall be available as indicated below to assist in caring for residents in the event of an emergency: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above by not first aid and amergency procedure training with night shfit staff which poses a potential health and safety risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator will review regulation and provide in-service training with staff who provides night supervision and submit a copy of training with staff signature to CCLD

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Lizette Francisco TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2023

Document Has Been Signed on 03/24/2023 06:11 PM - It Cannot Be Edited

FACILITY NAME: BLUEMEADOW CARE	FACILITY NUMBER: 079200825
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/24/2023

Type B

Section Cited

CCR

87412(f)

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: 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 by not maintaing records for S1 and S2 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator will review regulation and submit self-certification letter that records for S1 and S2 are maintained at facility to CCLD

Type B

Section Cited

CCR

87412(a)

(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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having complete records S1 and S2 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator will review regulations and submit self certification letter that all staff records are complete with the required documents including but not limited to: LIC 501, LIC 308 with TB test results, LIC 508, Employee Rights, and First Aid/CPR Certificate.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Lizette Francisco TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2023

Document Has Been Signed on 03/24/2023 06:11 PM - It Cannot Be Edited

FACILITY NAME: BLUEMEADOW CARE	FACILITY NUMBER: 079200825
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/24/2023

Type B

Section Cited

CCR

87411(d)

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: 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 by not having the required training for S2 which pose a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/07/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator will review regulation and obtain training for S2 and maintain training certificate on file and submit a copy to CCLD

Type B

Section Cited

CCR

87412(c)

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. 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 by not obtaining training required for S2 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/07/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator will review regulation and obtain training for S2 and maintain training certificate on file and submit a copy to CCLD

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Lizette Francisco TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2023

Document Has Been Signed on 03/24/2023 06:11 PM - It Cannot Be Edited

FACILITY NAME: BLUEMEADOW CARE	FACILITY NUMBER: 079200825
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/24/2023

Type B

Section Cited

HSC

1569.625(b)(1)

(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. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. 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 by not having the required training for S2 prior to employment which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/07/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator will review regulation and obtain training for S2 and maintain training certificate on file and submit a copy to CCLD

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Lizette Francisco TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2023

Document Has Been Signed on 03/24/2023 06:11 PM - It Cannot Be Edited

FACILITY NAME: BLUEMEADOW CARE	FACILITY NUMBER: 079200825
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/24/2023

Type B

Section Cited

HSC

1569.625(b)(2)

(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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not completing the required training for S3 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/07/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator will review regulation and obtain training for S3 and maintain training certificate on file and submit a copy to CCLD

Type B

Section Cited

HSC

1569.625(c)

(c) The training shall include, but not be limited to, all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, Licensee did not comply with the section cited above by not obtaining the training for S2 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator will review regulation and obtain training for S2 and maintain training certificate on file and submit a copy to CCLD

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Lizette Francisco TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2023

Document Has Been Signed on 03/24/2023 06:11 PM - It Cannot Be Edited

FACILITY NAME: BLUEMEADOW CARE	FACILITY NUMBER: 079200825
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/24/2023

Type B

Section Cited

CCR

87411(c)(1)

(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 by not having current first aid training for S1, S2 and S3 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator will obtain first aid training for all staff assisting with ADLs and submit a copy of certificate to CCLD

Type B

Section Cited

HSC

1569.626(a)

(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: 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 by not completing training requirements for S2 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/07/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator will review regulation and obtain training for S2 and maintain training certificate on file and submit a copy to CCLD

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Lizette Francisco TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2023

Document Has Been Signed on 03/24/2023 06:11 PM - It Cannot Be Edited

FACILITY NAME: BLUEMEADOW CARE	FACILITY NUMBER: 079200825
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/24/2023

Type B

Section Cited

HSC

1569.696(a)

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: 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 by not having required training for S2 once employed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/07/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator will review regulation and obtain training for S2 and maintain training certificate on file and submit a copy to CCLD

Type B

Section Cited

CCR

87506(a)

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. 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 by not maintaing R5's record at facility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/27/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator will review regulation and submit a self-certification letter to CCLD

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Lizette Francisco TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2023

Document Has Been Signed on 03/24/2023 06:11 PM - It Cannot Be Edited

FACILITY NAME: BLUEMEADOW CARE	FACILITY NUMBER: 079200825
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/24/2023

Type B

Section Cited

CCR

87468(c)(1)

(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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not posting personal rights and nondiscrimination notice which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	By POC date, Administrator will post the required postings and submit a photo to CCLD

Type B

Section Cited

HSC

1569.695(a)

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: 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 by not having an Emergency Disaster Plan on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	Administrator will submit a copy of LIC 610E to CCLD

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Lizette Francisco TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2023

Document Has Been Signed on 03/24/2023 06:11 PM - It Cannot Be Edited

FACILITY NAME: BLUEMEADOW CARE	FACILITY NUMBER: 079200825
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/24/2023

Type B

Section Cited

HSC

1569.695(c)

(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 by not having a record of emergency drill which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/27/2023
	Plan of Correction
1 2 3 4	By POC date, Adminsitrator will review regulation and conduct an emergency drill and submit a copy of drill to CCLD

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Lizette Francisco TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2023

FACILITY NAME: BLUEMEADOW CARE	FACILITY NUMBER: 079200825
	VISIT DATE: 03/24/2023