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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206795
Report Date: 08/18/2021
Date Signed: 08/18/2021 12:09:08 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:BLOSSOM CREEKS ASSISTED LIVINGFACILITY NUMBER:
107206795
ADMINISTRATOR:SAMRA, RAJVINDER KFACILITY TYPE:
740
ADDRESS:501 SOUTH APRICOT AVETELEPHONE:
(559) 598-9515
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY:6CENSUS: 3DATE:
08/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:13 AM
MET WITH:Baljinder Singh, Designated RepresentativeTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Lady Cabrera conducted an Annual Inspection on this date. LPA was met by Designated Representative Baljinder Singh and stated the purpose of the visit. Administrator Rajvinder Samra was available via phone. A tour of the facility was conducted. COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point.

Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathrooms have trashcans with lid. Hand washing posters were observed by the bathroom sink. Bedrooms were checked.

LPA checked residents’ medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health and infection control training. Facility staff was observed with mask on. Residents wear masks when away from the community.

No deficiencies were observed. Exit interview was conducted. Designated Representative was provided with the LIC809.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady CabreraTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021
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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