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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201376
Report Date: 10/16/2024
Date Signed: 10/16/2024 04:22:40 PM

Document Has Been Signed on 10/16/2024 04:22 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:BLOOMSTONE FAMILY HOME LLCFACILITY NUMBER:
019201376
ADMINISTRATOR/
DIRECTOR:		CHAN, COELESTIS P.FACILITY TYPE:
740
ADDRESS:674 GLENEAGLE AVENUETELEPHONE:
(650) 580-5285
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 6CENSUS: 6DATE:
10/16/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:50 PM
MET WITH:Coelestis Chan, applicant administrator.TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On this date, October 16, 2024, Licensing Program Analysts (LPAs) K. Nguyen and P. Manalo conducted an unannounced pre-licensing inspection, and met with Coelestis Chan, applicant administrator. Administrator application is for 6 (six) total capacity, 6 non-ambulatory (all).

LPA toured the facility with the applicant. Physical plant is consistent with the facility sketches submitted to Centralized Application Bureau (CAB). There is no body of water. Bedrooms were observed appropriately furnished with adequate lighting. Supplies of towels, bed sheets, linens were adequate. Equipment and supplies for residents' personal hygiene were available and on site. Food supplies were observed adequate for seven days of non-perishables. Facility is equipped with refrigerator, microwave, dishwasher, washer and dryer. Storage where knives and medications is centrally stored was observed.

Fire extinguisher checked, observed fully charge with tag showed serviced April 22, 2024. First aid kit checked and observed complete with manual. Hot water temperature was tested in one of the common bathrooms and measured at 106 degrees Fahrenheit. Carbon monoxide and smoke detectors were tested and observed operational.

......continued next page
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BLOOMSTONE FAMILY HOME LLC
FACILITY NUMBER: 019201376
VISIT DATE: 10/16/2024
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LPAs observed the following:

LPAs observed no indicator of specific resident live in units.

LPAs observed resident bed blocking the exit way.

LPAs observed the poster is not 20 x 26.

LPAs observed medication was cabinet was unlocked.

LPAs observed broken drawers, hole in the wall, broken fence in the backyard, trash need to be clear on both side of the facility, broken sink side panel, recliner chair need to be removed on the patio, and residents need to be kept clean/ sanitary.

Applicant to submit proof by October 30, 2024 showing all the 5 items are corrected.




LPA will inform CAB analyst upon receipt of proof of corrections. Final review of application, and license to be granted by CAB analyst.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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