Bluemeadow Care
RCFE · Memory Care
A Residential Care Facility for the Elderly (RCFE) is a non-medical residential care home licensed by California CDSS under Health & Safety Code §1560. Residents receive help with daily living activities such as bathing, dressing, and medication management. An RCFE with a Memory Care designation is additionally required by California Title 22 (§87705 and §87706) to provide specialized staff training in dementia care, individualized care plans for residents with cognitive impairment, and appropriate supervision protocols — requirements that go beyond a standard RCFE license.
3262 Montevideo Dr · San Ramon, 94583
Quick facts
Quality snapshot
Updated April 25, 2026Compared to 182 California RCFE memory care facilities of similar size, over the last 36 months.
Source: California Department of Social Services, Community Care Licensing Division. View raw inspection records →
Quality grade· click to show how this was calculated
Severity24thWeighted citations per bed
Repeats100thRepeat deficiencies as share of total
Frequency12thDeficiencies per inspection
Tick mark at 50% = peer median · higher percentile = better facility
Quality grade· click to show how this was calculated
Weighted citations per bed
Repeat deficiencies as share of total
Deficiencies per inspection
Tick mark at 50% = peer median · higher percentile = better facility
Bluemeadow Care scores C−. Better than 45% of comparable California RESIDENTIAL CARE ELDERLY facilities. Severity: 24th percentile. Repeats: top 0%. Frequency: bottom 12%.
Each metric is converted to a 0–100 percentile within the peer set (higher = better). The composite grade averages all four. Peer set: CA / rcfe_memory_care / small beds (182 facilities).
Citation severity over time
↓ improvingWeighted severity score per month · 24 months
Weighted score (24mo)
81
Last citation
Apr 26
Finding distribution
20 total · 36 monthsScope × Severity (CMS A–L)
The rules that apply to this facility
California Title 22 requirements for this facility, with the specific regulation and a suggested question for each.Rules this facility has been cited for are shown first.
What dementia-care training must staff complete?Cited Sep 202422 CCR §87705 / HSC §1569.625
Because this facility markets dementia or Alzheimer's care, state law mandates higher training standards:
- 12 hours initial dementia training — 6 hours before a staff member works independently with residents, 6 more within the first 4 weeks.
- 8 hours annual dementia in-service — required every year thereafter.
- Administrator CE — the administrator must include 8 hours of dementia-specific continuing education in every 2-year recertification cycle.
Training must cover individualized care plans, behavioral expressions, appropriate supervision, and the facility's dementia care philosophy.
Ask on tour: Ask how dementia training records are kept — families may request documentation.
How many staff must be on duty overnight?Cited Mar 202322 CCR §87415
Based on 6 licensed beds:
One qualified staff member must be on call and physically on premises at all times overnight.
Violation pattern to watch for:A facility that documents a staff member as "on call" but with that person physically off-site — when the law requires on-premises presence — is in violation of this section.
Ask on tour: Ask the facility to walk you through their overnight staffing plan and confirm whether on-call staff are on premises or off-site.
What health conditions can this facility legally accept or refuse?22 CCR §87612–87615
Restricted — allowed with physician order + care plan
- Supplemental oxygen
- Insulin and injectable medications
- Indwelling or intermittent catheters
- Colostomy / ileostomy
- Stage 1 and Stage 2 pressure injuries
- Wound care (non-complex)
- Incontinence
- Contractures
Prohibited — facility must refuse or discharge
- Stage 3 or Stage 4 pressure injuries
- Feeding tubes (PEG, NG, or J-tube)
- Tracheostomies
- Active MRSA or communicable infections requiring isolation
- 24-hour skilled nursing needs
- Total ADL dependence with inability to communicate needs
A hospice waiver (HSC §1569.73) can allow continued care for residents on hospice who would otherwise fall into a prohibited category.
Ask on tour: Ask whether your loved one's specific care needs are restricted or prohibited, and what the facility's process is if needs change after admission.
What must this facility report to the state — and how fast?22 CCR §87211 / WIC §15630
- ImmediateElopement, fire, epidemic outbreak, or poisoningImmediately
- 2 hoursAbuse with serious bodily injury2-hour phone report + 2-hour written report — to the California Department of Social Services (CDSS), Adult Protective Services, and law enforcement
- 24 hrsAbuse without serious bodily injuryWithin 24 hours
- Next dayDeath of a residentPhone by next working day; written within 7 days
- Next dayInjury requiring medical treatment beyond first aidPhone by next working day; written within 7 days
- WrittenBankruptcy, foreclosure, eviction, or utility shutoff noticeWritten notice to CDSS and residents — $100/day penalty (max $2,000) for failure
Your enforcement lever:Incidents that aren't reported on time are themselves a separate violation. If you believe a reportable event wasn't filed, you can submit a complaint directly to the California Department of Social Services (CDSS).
How does CDSS enforce these rules?22 CCR §87755–87777 / HSC §1569.58
- 1Notice of DeficiencyWritten citation with a correction deadline. Facility must submit a Plan of Correction.
- 2Civil PenaltyStarts at $50/day for non-serious; $150/day for serious deficiencies — immediately, with no grace period. Repeats escalate to $150 first day + $50/day, then $1,000 first day + $100/day.
- 3Suspension of AdmissionsFacility cannot accept new residents until violations are corrected.
- 4Temporary Suspension or RevocationEmergency suspension for imminent danger; full revocation after administrative hearing.
- 5Exclusion OrderAdministrator and operator can be barred from all CDSS-licensed facilities — not just this one.
See how these rules have been applied to this specific facility:
View state inspection record and citationsState records
California Dept. of Social Services · Community Care Licensing- License number
- 079200825
- License type
- RESIDENTIAL CARE ELDERLY
- License status
- LICENSED
- License expires
- Not yet indexed
- Licensed beds
- 6
- Operator
- Bluemeadow Care, Llc
Inspections & citations
10
reports on file
45
total deficiencies
7
Type A (actual harm)
4
dementia-care citations
Other visitApril 17, 2026Type B1 deficiency
Plain-language summary
During a follow-up visit on April 17, 2026, inspectors found two staff members sleeping in a makeshift bedroom set up in the garage with a curtain, personal items, and music playing. This violated state regulations requiring staff to maintain proper working conditions. The facility has been cited and must submit a plan to correct this violation.
View full inspector notes
On 04/17/2026 at 3:00PM, Licensing Program Analyst (LPA) A Gomez conducted a case management as a result of observations during complaint visit 15-AS-20260413084301 . LPA met with Caregiver, Edel Ann Manga, and explained the purpose of the visit. Administrator Yanlin "Cynthia" Huang was unavailable and approved caregiver to sign off on report via telephone call. While conducting the complaint investigation LPA observed 2 staff sleeping in the garage on a bed in a makeshift bedroom. LPA observed that the are had a curtain put up for privacy, personal items, music playing, and staff asleep in the area. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, a copy of this report and appeal rights provided.
Regulation
(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 the residents, staff, and others who may reside in the facility. The following provisions shall apply: This requriment was not met as evidence by:
Inspector finding
Based on observation, the licensee did not comply with the section cited above in having staff sleeping in the garage which poses a potential personal rights risk to persons in care.
ComplaintDecember 24, 2025Type A1 deficiency
Plain-language summary
During an investigation into a complaint about inadequate medication assistance, inspectors found medications stored unsecured in an unlocked kitchen drawer and unlocked medication closet, making them accessible to residents. The facility was cited for this deficiency during visits on October 17 and December 24, 2025, and was given a deadline to correct the problem. The facility was notified that failure to fix this issue could result in additional penalties.
View full inspector notes
On 12/24/2025 at 8:30 AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to deliver amended report for complaint #15-AS-20251010103344 and cite for deficiencies observed during the investigation. LPA met with Administrator, Yanlin Cynthia Huang and explained the purpose of the visit. During the course of the investigation for allegation " Facility did not provide adequate medication assistance" LPA observed the medication unlocked in the kitchen drawer and medication closet unlocked. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT ON 10/17/2025 AND 12/24/2025: Medications not secured and locked (kitchen drawer and med closet unlocked with centrally stored medications accessible) Amended report delivered to Executive Director. 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.
Regulation
(h) The following requirements shall apply to medications which are centrally stored:(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidence by:
Inspector finding
Based on LPA's observation the licensee did not coply with the section cited above by med closet and kitchen drawer containing centerally stored medication unlocked which posed an immediate safety risk to residents in care.
InspectionOctober 17, 2025· SubstantiatedType B1 deficiency
Inspector: Alona Gomez
Regulation
(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 requirment was not met evidence by:
Inspector finding
Based on LPA's observation and interview the licensee did not coply with the section cited above by having perscription medication transferred into a container which posed a potential safety and personnel rights risk to residents in care.
InspectionSeptember 17, 2025Type B2 deficiencies
Plain-language summary
A routine annual inspection was conducted on September 17, 2025, and found that the facility maintains safe living conditions with proper temperature control, working smoke and carbon monoxide detectors, secure medication storage, and accessible grab bars in bathrooms. The inspection identified deficiencies including a missing emergency disaster plan, four resident files lacking required service assessments, and an emergency drill not conducted since September 2024. The facility was given time to correct these issues.
View full inspector notes
On 9/17/25 at 8:00 AM, Licensing Program Analyst (LPA) A. Gomez 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 1 may be bedridden. Room 6 only is approved for bedridden. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are occupied by the residents and 1 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 71 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 113.9 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 purchased on 9/17/2025. Emergency Disaster Plan not available. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 9/1/2024. At 10:30am, LPA reviewed 5 residents records. Resident files missing appraisal and needs of services for R1,R2, R3, and R5. At 11:12 am, LPA reviewed 4 staff records and 3 of 3 have current first aid training and associated to the facility. 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
Regulation
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, th…
Inspector finding
Based on record review, the licensee did not comply with the section cited above in 4 out of 5resident records review not having an up to date appraisal of needs and services which poses a potential personal rights risk to persons in care. POC Due Date: 10/01/2025 Plan of Correction 1 2 3 4 By POC facility agrees to review residents files and up date them as neccessaey and notify CCLD.
Regulation
(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,…
Inspector finding
Based on record review, the licensee did not comply with the section cited above in not having done any quaterly drills in 2025 which poses a potential safety risk to persons in care. POC Due Date: 10/01/2025 Plan of Correction 1 2 3 4 By POC facility agrees to conduct drills and notify CCLD.
InspectionSeptember 4, 2024Type A15 deficiencies
Inspector: Alona Gomez
Plain-language summary
During a routine annual inspection on September 4, 2024, inspectors found multiple safety and care concerns: medications and a knife were left unsupervised and accessible, the medication closet was unlocked, a staff member without proper clearance was present at the facility, staff training and certifications were not current, some residents' medical records were incomplete or expired, the facility did not maintain adequate food supplies, and damaged screens on doors and windows needed repair. The inspectors also observed that a staff member was sleeping in the common area during overnight care and that residents lacked access to stimulating activities. The facility was assessed a $500 civil penalty.
View full inspector notes
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 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 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.
Regulation
(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).
Inspector finding
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 1 2 3 4 Staff put knife away
Regulation
(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 …
Inspector finding
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 1 2 3 4 Individual left during visit. Civil Penalty Assesed
Regulation
(c) All window screens shall be clean and maintained in good repair.
Inspector finding
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 1 2 3 4 By POC Licensee agrees to repair or replace screens and notify CCLD.
Regulation
(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:
Inspector finding
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 1 2 3 4 By POC Licensee agrees to review and update staff files and notify CCLD.
Regulation
(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 subdivisi…
Inspector finding
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 1 2 3 4 By POC Licensee agrees to provide trainings and record the competions and notify CCLD.
Regulation
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
Inspector finding
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 1 2 3 4 By POC Licensee agrees to provide trainings and record the competions and notify CCLD.
Regulation
(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 Priva…
Inspector finding
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 1 2 3 4 By POC date Licensee agrees to post required information and notify CCLD.
Regulation
(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…
Inspector finding
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 1 2 3 4 By POC Licensee agrees to no longer allow staff to sleep in common areas.
Regulation
(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: (…
Inspector finding
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 1 2 3 4 By POC date Licensee agrees to post the required signs and notify CCLD
Regulation
(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:
Inspector finding
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 1 2 3 4 By POC date Licensee agrees to develop and implement an activities schedule and notify CCLD
Regulation
(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.
Inspector finding
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.
Regulation
(b) Each resident's record shall contain at least the following information:
Inspector finding
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 1 2 3 4 By POC date Licensee agrees to review all clients files and update and notify CCLD
Regulation
(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,…
Inspector finding
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
Regulation
(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 …
Inspector finding
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
Regulation
(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).
Inspector finding
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.
ComplaintApril 4, 2023· SubstantiatedType B1 deficiency
Inspector: Carol Fowler
Regulation
(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:
Inspector finding
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.
InspectionMarch 24, 2023Type A20 deficiencies
Inspector: Lizette Francisco
Plain-language summary
During a routine annual inspection on March 23, 2023, inspectors found that the facility's hot water temperature exceeded safe limits at 141 degrees Fahrenheit, a bed was being used as a sleeping area in the garage, and staff records with required training documentation were not maintained at the facility. The facility otherwise maintained safe conditions including working smoke detectors, carbon monoxide detectors, fire extinguishers, adequate lighting, grab bars in bathrooms, and locked storage for medications and sharps. A $500 civil penalty was assessed.
View full inspector notes
On 3/23/2023 starting 10:10 AM, Licensing Program Analysts (LPAs) L. Francisco and L. Fici arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Administrator, Yanlin "Cynthia" Huang and explained the purpose of the visit. The facility’s fire clearance was approved for all six (6) non-ambulatory residents of which 1 may be bedridden. There were 2 staff and 5 residents present during inspection. Starting at 10:25 AM, LPAs toured facility with Administrator including but not limited to bedrooms, 2 bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are for residents and 1 bedroom is for staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 68 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in residents’ shared bathroom was measured at 141 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. Sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was observed fully charged. First aid kit was observed to be complete. Starting at 11:30 AM, LPAs reviewed 4 of 5 residents records. At 12:30 PM, LPAs reviewed 1 of 3 staff records. At 4:00 PM, LPAs reviewed a sample of resident’s medications. REPORT CONTINUES ON 809C 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 THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: -At 10:40 AM, LPA observed hot water temperature is maintained at 141 degrees F -At 10:45 AM, LPA observed a bed in garage and being used as a sleeping area. -Starting at 11:38 AM during record review, LPAs observed no files are being maintained for S1 and S2. Required training were missing. Records for R5 was not maintained at facility. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 3/31/2023: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Current Administrator’s Certificate 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. An immediate $500 Civil Penalty is being assessed. Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.
Regulation
(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 fi…
Inspector finding
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 bei…
Regulation
(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 degre…
Inspector finding
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.
Regulation
(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.
Inspector finding
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.
Regulation
(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 …
Inspector finding
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.
Regulation
(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 sta…
Inspector finding
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
Regulation
(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…
Inspector finding
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
Regulation
(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:
Inspector finding
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
Regulation
(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:
Inspector finding
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 Ri…
Regulation
(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:
Inspector finding
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
Regulation
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.
Inspector finding
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
Regulation
(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, …
Inspector finding
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
Regulation
(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 subdivisi…
Inspector finding
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
Regulation
(c) The training shall include, but not be limited to, all of the following:
Inspector finding
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
Regulation
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
Inspector finding
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
Regulation
(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:
Inspector finding
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
Regulation
(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:
Inspector finding
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
Regulation
(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.
Inspector finding
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
Regulation
(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 Priva…
Inspector finding
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
Regulation
(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:
Inspector finding
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
Regulation
(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,…
Inspector finding
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
ComplaintJanuary 12, 2023· MixedNo deficiencies
Inspector: Lizette Francisco
Mixed — CDSS found some allegations substantiated and others unsubstantiated during this investigation.
Plain-language summary
A complaint investigation found that facility staff failed to follow wound care instructions for a resident with a pressure injury on the heel, resulting in the wound worsening to Stage 4 with exposed bone and a serious bacterial infection that required hospitalization; the facility was also unable to explain how the resident sustained a bleeding eye injury around the same time. Other complaints about staffing levels, dignity, and notification of family about changes in condition were either unsubstantiated or dismissed as unfounded. The facility received a $500 civil penalty, with additional penalties pending related to the serious injury.
View full inspector notes
The Department investigated resident developed a pressure injury requiring hospitalization. Based on record review, R1 was admitted to the facility on June of 2015 under the prior License. Sometime in April 2020, R1’s right heel bumped on the wheelchair. On 4/8/2020, R1’s wound was diagnosed unstageable by attending physician at John Muir Hospital and wound care was initiated. The same day, home health nurse instructed facility staff to supervise R1 at all times, to off-load pressure to right heel at all times, feed R1 with high protein diet and to reposition every two hours. On 5/18/2020 and 6/5/2020, Home Health Nurse observed R1’s wound pressed against the bed despite instructions to off-load and elevate the heel with pillows. On 6/9/2020, R1 was admitted to Emergency Department and the pressure injury was diagnosed at Stage 4. Bone was exposed and 60% of the heel was necrotic tissue. Test results revealed R1 had Osteomyelitis due to bacterial infection which infected R1’s bloodstream. The Department investigated resident had an unexplained injury. On 5/28/2020, facility staff informed home health nurse that R1 had fallen from the wheelchair earlier in the day and sustained a skin tear to the chin when R1 leaned over in the wheelchair to pick up something. On 6/9/2020, caregiver advised R1’s left eye had been bleeding for the past two days but could not explain why or how R1 sustained the injury. Upon R1’s admission to the Emergency Department on 6/9/2020, R1 was diagnosed with bilateral conjunctivitis. Based on the Department’s observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8) and Health and Safety Code are being cited on the attached LIC 9099D. A $500 Civil Penalty is being assessed. Civil penalty determination related to serious bodily injury is pending. Exit interview conducted. Appeal rights and a copy of this report was provided to Administrator. 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 The Department investigated residents needs are not being met due to insufficient staffing. Based on interview with 3 staff and 3 residents, 3 of 3 staff and 3 of 3 residents stated that there are no issues with staffing. The Department investigated resident not afforded dignity while in care. Based on interview with 3 residents, 2 of 3 residents stated they are provided with privacy. During an interview with 3 staff, 3 of 3 staff stated they close the door when they are changing the residents and assisting residents in the bathroom. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation are UNSUBSTANTIATED . Exit interview conducted with Administrator and a copy of this report provided. 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 Based on documents reviewed, facility contacted home health nurses regarding R1’s health status. This agency has investigated the complaint alleging staff did not notify resident’s authorized representative of resident’s change in condition. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint. There is no deficiency noted. Exit interview was conducted with Administrator and a copy of this report was provided.
Other visitJanuary 12, 2023Type A3 deficiencies
Inspector: Lizette Francisco
Plain-language summary
Inspectors conducted a case management visit on January 12, 2023 following a complaint and found that the facility failed to report incidents to the state licensing agency, including a resident's fall from a wheelchair that caused a chin laceration in April 2020 and another resident's bleeding eyes observed in May 2020. During the visit, inspectors also found that one resident's care plan was not current and that laundry detergent was left on top of a dryer in an unlocked laundry room. The facility was cited for these violations and given a deadline to correct them.
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On 1/12/2023 at 11:40 AM, Licensing Program Analysts (LPAs) L. Francisco and C. Lin conducted a Case Management (CM) and met with Administrator, Yanlin "Cynthia" Huang . LPAs explained to Administrator that this CM is being conducted in connection with a complaint investigated by the Department. During the course of investigation, the Department observed R1 fell off the wheelchair and sustained a cut on the chin in April 2020. On May 28, 2020, R1 was observed with bleeding eyes. The facility failed to send incident reports to CCL. While at the facility on 1/12/2023, LPAs observed the following deficiencies: -At 9:58 AM, LPAs observed R4 does not have an updated appraisal plan on file. -At 10:35 AM, LPAs observed laundry detergent on top of the dryer inside the unlocked laundry room. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. 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 to Administrator.
Regulation
87705(f)(2) CARE OF PERSONS WITH DEMENTIA (f)The following shall be stored inaccessible to residents with dementia:(2)...and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
Inspector finding
Based on observation, Licensee did not comply with regulation cited above. LPAs observed unlocked cleaning supplies in unlocked laundry room which poses an immediate health and safety risk to persons in care.
Regulation
87411(a)(1)(D) REPORT REQUIREMENTS (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the…(D) Any…
Inspector finding
Based on record review, Licensee did not comply with the regulation cited above. Facility did not submit incident reports for when R1 fell off the wheelchair and sustained a cut on the chin in April 2020. In addition on May 28, 2020 where R1 was observed with bleeding eyes which poses a potential health and safety risk to persons in care.
Regulation
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 .... and a reappraisal done at least annually...
Inspector finding
Based on record review, Licensee did not comply with the regulation cited above. LPAs observed R4 does not have an updated appraisal on file which poses a potential health and safety risk to persons in care.
ComplaintOctober 12, 2021Type B1 deficiency
Inspector: Lizette Francisco
Plain-language summary
This was an unannounced inspection on October 12, 2021 focused on infection control practices at the facility. The inspector found that staff were wearing proper protective equipment, the facility had adequate supplies of food and protective equipment on hand, and had screening procedures in place, but noted that the facility did not have a required Emergency Disaster Plan on file. The facility was given a deadline to correct this deficiency.
View full inspector notes
On 10/12/2021 starting at 11:40am, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator, Yanlin Huang and explained the purpose of the visit. During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan on file. The following deficiency was observed: -At 12:35pm during record review, LPA observed no Emergency Disaster Plan (LIC 610E) maintained at the facility. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.
Regulation
(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:
Inspector finding
Based on record review, licensee did not comply with the section cited above. LPAs observed no Emergency Disaster Plan is maintained at facility which poses a potential health and safety risk to persons in care. POC Due Date: 10/15/2021 Plan of Correction 1 2 3 4 Administrator agrees to maintain an Emergency Disaster Plan (LIC 610E) and submit a copy to CCL by POC date.
Federal summary
CMS Care CompareNot a CMS-certified facility
California RCFEs (residential care facilities for the elderly) are licensed by the state, not by CMS. CMS data only applies to skilled nursing facilities or to CCRCs that operate a licensed SNF wing.
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