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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002224
Report Date: 05/11/2023
Date Signed: 05/11/2023 03:19:02 PM


Document Has Been Signed on 05/11/2023 03:19 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:ALMOND BLOSSOM SENIOR CAREFACILITY NUMBER:
045002224
ADMINISTRATOR:RAMOS, EDUVIJESFACILITY TYPE:
740
ADDRESS:1036 BLACKMUIR COURTTELEPHONE:
(530) 342-1813
CITY:CHICOSTATE: CAZIP CODE:
95926
CAPACITY:6CENSUS: 6DATE:
05/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Emily Lanser and Sarah MummertTIME COMPLETED:
03:30 PM
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LPA Hiratsuka conducted this unannounced annual visit. LPA toured the facility with the caregiver on duty. Administrator Emily Lanser and Administrator in Training Sarah Mummert both arrived and completed the visit.

This facility has four private resident rooms and one shared resident room. There is an office to the left of the main entrance. The main common area has the kitchen, dining, and sitting area. There is a small area behind the kitchen that has a private resident room off of it, a door leading to the garage, and in the small area itself stores the medication and the clothes washer and dryer. The backyard has a pool that is surrounded by a five foot fence and has a lock on the gate.

During today's visit the following was completed by LPA:
-medication review
-two resident files reviewed
-one staff file reviewed
-tour the facility

Multiple topics were discussed.

No deficiencies cited.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023
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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