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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201427
Report Date: 10/23/2024
Date Signed: 10/23/2024 02:54:51 PM

Document Has Been Signed on 10/23/2024 02:54 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:BLOSSOMS CARE HOMEFACILITY NUMBER:
079201427
ADMINISTRATOR/
DIRECTOR:		CHEUNG, DIANAFACILITY TYPE:
735
ADDRESS:106 VIOLET ROADTELEPHONE:
(510) 313-0272
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY: 6CENSUS: 0DATE:
10/23/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:DIANA CHEUNG, ADMINISTRATORTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 10/23/2024 at 1:00pm, Licensing Program Analyst (LPA) Carol Fowler conducted an announced pre-licensing. LPA met with Diana Cheung, Administrator, and explained the purpose of the visit. The facility has an approved fire safety clearance for four (4) ambulatory clients and two (2) non-ambulatory clients.

LPA inspected the facility inside and out including but not limited to the bedrooms, bathrooms, common living areas, kitchen, garage, back yard. The facility has a three (3) bedrooms downstairs and three (3) bedrooms upstairs which one will be occupied by staff and one by Administrator and a total of three (3) bathrooms. No bodies of water observed. There is sufficient lighting around the facility. Clients rooms are equipped with the proper furniture, bedding, and lighting. Locked cabinets available to store medications, toxins and sharps. Hot water temperature is measured at 120.6 degrees Fahrenheit in shared clients' bathroom. Carbon monoxide and smoke detectors present and operable. Facility inspection matches the sketch that was provided.

Facility needs to correct the following by 11/11/2024:

· Purchase window covering for bedroom 3.
· Remove items bedframe, 2 ladders, shovel, rake from the unlocked garage.
· Remove 2 large logs located in the front yard.
· Remove the ladder on the side of the storage unit.
· Enlarge complaint poster (see something say something) to 20" X 26".

Continued on LIC809C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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: BLOSSOMS CARE HOME
FACILITY NUMBER: 079201427
VISIT DATE: 10/23/2024
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continue from LIC 809
  • Post residents rights.


Issues were noted during inspection. LPA observed that facility is not ready to be licensed. This report will be submitted to the Central Applications Bureau (CAB) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAB. Additional requirements may still be required.

Exit interview conducted with Licensee and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC809 (FAS) - (06/04)
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