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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
079201427
Report Date:
10/28/2024
Date Signed:
10/28/2024 02:18:23 PM
Document Has Been Signed on
10/28/2024 02:18 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 HOME
FACILITY NUMBER:
079201427
ADMINISTRATOR/
DIRECTOR:
CHEUNG, DIANA
FACILITY TYPE:
735
ADDRESS:
106 VIOLET ROAD
TELEPHONE:
(510) 313-0272
CITY:
HERCULES
STATE:
CA
ZIP CODE:
94547
CAPACITY:
6
CENSUS:
0
DATE:
10/28/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:
DIANA CHEUNG, ADMINISTRATOR
TIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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An announced Pre-licensing Comp III associated with Pre-Licensing Inspection done on `10/28/2024 at 1:10 PM was conducted by Licensing Program Analysts (LPAs) Carol Fowler and David Doidge. Comp III was attended by Diana Cheung Administrator.
LPAs discussed the power point after which LPAs observed Licensee Diana Cheung with a better and clear understanding of Title 22 regulations and Community Care Licensing in general.
LPAs concluded Comp III.
No citation made during this visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME
:
Bennett Fong
LICENSING EVALUATOR NAME
:
Carol Fowler
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/28/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/28/2024
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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