015601204-7-22-2025-15-AS-KHOS-DJZQEV-20250728120658

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601204
Report Date: 07/16/2025
Date Signed: 07/22/2025 03:15:31 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/05/2025 and conducted by Evaluator Patricia Manalo

COMPLAINT CONTROL NUMBER: 15-AS-20250605155729

FACILITY NAME:	LUCKY GARDEN CARE HOME		FACILITY NUMBER:	015601204
ADMINISTRATOR:	JOE, ISABELLA		FACILITY TYPE:	740
ADDRESS:	42745 PEACHWOOD STREET		TELEPHONE:	(510) 673-6399
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY:	6	CENSUS: 3	DATE:	07/16/2025
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Isabella Joe, Administrator		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Staff did not provide resident(s) with adequate food supply
Staff are not providing medication as prescribed

INVESTIGATION FINDINGS:

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*This is an Amended Report issued 07/16/2025*

On 07/16/2025 at 8:55 AM, Licensing Program Analyst (LPA) P.Manalo arrived unannounced to deliver finding on the above allegations.

During the course of investigation, LPA conducted a 10-day visit to tour the facility and interviewed Administrator (ADM), Staff 1 (S1), Resident 1 (R1) and Witness 1 (W1) on 06/06/2025. LPA obtained the Centrally Stored Medication and Destruction Record, Identification and Emergency Information, Resident’s On Lok Medication Card, Physician’s Report, Staff Medication Training, and Email Correspondence between 06/30/2025 to 07/01/2025 with Witness 2 (W2).

Continue LIC9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2025

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

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20250605155729

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LUCKY GARDEN CARE HOME	FACILITY NUMBER: 015601204
	VISIT DATE: 07/16/2025

NARRATIVE

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Continue from LIC9099... *This is an Amended Report issued 07/16/2025*

It was alleged that; Staff are not providing medication as prescribed. Based on interviews with ADM conducted on 06/06/2025, it was found that 2 out of 3 resident’s medications are delivered on a weekly basis and will arrive at the facility on Fridays. W1 stated that the facility can either have the medication delivered monthly or weekly, and the facility requested to have the Medication Pack to arrive every Friday. W2 confirmed on 06/30/2025 that the pharmacy contracted provides residents’ medications on a weekly basis so that if there’s any changes in medications, it can be implemented within a week instead of monthly basis. Email Correspondence between W2 also confirmed the weekly basis delivery for the residents’ medications.

LPA conducted a facility tour on 06/06/2026 and observed S1 unlocking the medication cabinet during the visit. LPA also observed R1’s Medication Bubble Pack dated from 06/07/2025 to 06/13/2025 at the facility. ADM stated R2’s medication will be delivered later today by the pharmacy.

It was alleged that; Staff did not provide resident(s) with adequate food supply. Based on interviews with ADM it was revealed that the facility will purchase food every 3 days for the residents. Interview with R1 indicated that R1 enjoys the food at the facility. R2 and R3 were not at the facility on 06/06/2025 for an interview.

LPA toured the facility and observed S1 preparing dumplings for resident’s meals. LPA inspected food supplies in the fridge and freezer that contains oranges, bananas, vegetables, meat products, and etc. During the annual visit conducted on 05/08/2025, LPA toured the facility and observed enough canned goods for each resident in care.

Based on interviews and observations conducted, the above allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

There is no deficiency noted.

Exit interview was conducted with Administrator, and a copy of this report was provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2025

LIC9099 (FAS) - (06/04)

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