015601482-12-9-2021-15-AS-ADEO-C9K3RT-20211209172918

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601482
Report Date: 12/09/2021
Date Signed: 12/09/2021 05:31:23 PM

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:	BLOSSOM GARDEN SENIOR HOME		FACILITY NUMBER:	015601482
ADMINISTRATOR:	HYESUS, FEKERTE		FACILITY TYPE:	740
ADDRESS:	21307 WESTERN BLVD		TELEPHONE:	(510) 363-8566
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	9	CENSUS: 8	DATE:	12/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Fekerte Hyesus/Administrator and Avelina Sagnep/Co-Administrator		TIME COMPLETED:	05:40 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	Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection controls annual inspection. LPA met with Avelina Sagnep, co-administrator, and informed the purpose of visit. Avelina Sagnep called Fekerte Hyesus, administrator, who arrived after about 20 minutes. Facility has an approved LIC808 COVID-19 Mitigation Plan. LPA inspected the facility inside and out with Avelina Sagnep. LPA observed screening station located near the front entrance with visitor's log, hand sanitizer and no touch temperature probe. Routine symptom screening (+/-) temperature and symptom checks are done at entry for all staff and visitors. Trash bins were observed with pedal operated lids. Medications are centrally stored in the a locked cabinet. Centrally stored PPEs inspected. There were at least 7 days of nonperishable and 2 days of perishable food supplies. Fire extinguisher was observed fully charge and tag showed serviced November 8, 2021. Smoke and carbon monoxide detectors were operational. First aid kit inspected and observed complete with manual. LPA observed the following:, 1. Visitor's poster at the entrance door outdated. 2. No COVID-19 signages inside the facility except in the common bathroom and kitchen. 3. Disposable gowns and N95 respirators not sufficient for 30 days for 5 staff. ......continued on 809C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

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

LIC809 (FAS) - (06/04)

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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: BLOSSOM GARDEN SENIOR HOME	FACILITY NUMBER: 015601482
	VISIT DATE: 12/09/2021

NARRATIVE

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LPA verified and Avelina Sagnep stated the following:
1. Staff are not fit tested for N95 respirator.
2. Residents' temperature are no longer routinely checked.

LPA requested for copies of the following updated documents to be submitted by December 23, 2021:
1. LIC500 Personnel Report
2. LIC308 Designation of Facility Responsibility
3. LIC610E Emergency Disaster Plan
4. Proof of $3M liability insurance coverage

No citation issued during today's inspection.

Exit interview conducted and copy of this report provided to Fekerte Hyesus.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

LIC809 (FAS) - (06/04)

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