079201170-12-21-2023-15-AS-LAWN-CYQU56-20231221141612

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201170
Report Date: 12/21/2023
Date Signed: 12/21/2023 02:16:19 PM

Document Has Been Signed on 12/21/2023 02:16 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	ASTER GARDEN CARE HOME, INC		FACILITY NUMBER:	079201170
ADMINISTRATOR:	RHU, JINYOUNG		FACILITY TYPE:	740
ADDRESS:	2046 ARNOLD DRIVE		TELEPHONE:	(925) 407-7065
CITY:	MARTINEZ	STATE: CA	ZIP CODE:	94553
CAPACITY:	6	CENSUS: 0	DATE:	12/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Jinyoung Rhu, Licensee/Administrator		TIME COMPLETED:	02:30 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 12/21/2023 at 12:45PM, Licensing Program Analyst (LPA) Lori Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Licensee/Administrator, Jinyoung "Jin" Rhu and explained the purpose of the visit. The facility’s fire clearance was approved for 6 non-ambulatory, of which 1 may be bedridden. Hospice waiver for 4. Administrator's Certificate #6014268740 Expires 05/17/2024. Currently the facility doesn't have any residents. LPA toured facility with Jin including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 8 total bedrooms which 5 bedrooms are occupied by the residents and 3 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 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 120.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 07/17/2023. Emergency Disaster Plan was last posted on 12/21/2023. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 11/27/2023. LIC809-C Continued....

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

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

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ASTER GARDEN CARE HOME, INC	FACILITY NUMBER: 079201170
	VISIT DATE: 12/21/2023

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
26
27
28
29
30
31
32

LIC809 Continued...

LPA reviewed 6 staff records and 6 of 6 have current first aid training and associated to the facility.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 12/28/2023:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2