<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201076
Report Date: 11/21/2024
Date Signed: 11/21/2024 02:09:32 PM

Document Has Been Signed on 11/21/2024 02:09 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:CHERRY BLOSSOM ADULT CARE, INC.FACILITY NUMBER:
019201076
ADMINISTRATOR/
DIRECTOR:		ACOSTA, NIDAFACILITY TYPE:
735
ADDRESS:625 FOLSOM AVENUETELEPHONE:
(510) 676-8518
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 4CENSUS: 4DATE:
11/21/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Billy Leung, Co-LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:20 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
On 11/21/24 at 1:30PM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct a case management health & safety check and met Billy Leung, Co- License. Co-Licensee called and spoke with Ricky Ng Administrator (ADM) and informed the purpose of visit. ADM was not available to come and gave verbal permission for Billy to sign the report.

During the health and safety check, LPA observed no clients and one staff at facility. LPA toured facility with staff, including but not limited to bedrooms, kitchen, bathroom, and common areas. Clients in care appear to be safe and there are no imminent health/safety concerns on today's date.



No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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 1