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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601482
Report Date: 11/11/2022
Date Signed: 11/11/2022 05:17:09 PM


Document Has Been Signed on 11/11/2022 05:17 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:BLOSSOM GARDEN SENIOR HOMEFACILITY NUMBER:
015601482
ADMINISTRATOR:HYESUS, FEKERTEFACILITY TYPE:
740
ADDRESS:21307 WESTERN BLVDTELEPHONE:
(510) 363-8566
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY:9CENSUS: 6DATE:
11/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:05 PM
MET WITH:Fekerte Hyesus/AdministratorTIME COMPLETED:
05:20 PM
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA met with Fekerte Hyesus, administrator, and informed the purpose of visit.

Facility has LIC808 Mitigation Plan on file.

LPA toured the facility inside out with the administrator. LPA inspected the living room, dining area, kitchen, bedrooms, bathrooms, side and backyard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days.

LPA observed screening station located near the entrance with visitor's log, hand sanitizer and thermometer. Surgical masks and disposable gloves are readily available at the screening station. Temperature and symptoms check are done at entry for visitors. Antigen test kits are readily available. Residents and staff are screened for COVID-19 symptoms and temperature is checked and recorded. COVID-19 signages were observed posted all throughout the facility. Supplies of PPEs inspected. Staff were fit tested for N95 respirators.

Hot water temperature in the common bathroom was tested and measured at 105.2 degrees Fahrenheit. Fire extinguishers checked, observed fully charge with tags showed serviced November 8, 2021.

Administrator provided to LPA on this day copies of the following:
1. New Infection Control Plan
2. $3M liability insurance certificate

......continued on 809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 11/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/11/2022
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: 11/11/2022
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Administrator to submit the following by November 25. 2022:
1. Monkeypox Infection Control Plan
2. LIC308 Designation of Facility Responsibility
3. LIC500 Personnel Report
4. LIC610E Emergency Disaster Plan (9 pages)

No deficiency observed.

Exit interview conducted and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/11/2022
LIC809 (FAS) - (06/04)
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