107206795-8-20-2024-24-AS-BMIA-D8BLK4-20240820084851

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107206795
Report Date: 08/17/2024
Date Signed: 08/20/2024 08:49:38 AM

Document Has Been Signed on 08/20/2024 08:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	BLOSSOM CREEKS ASSISTED LIVING		FACILITY NUMBER:	107206795
ADMINISTRATOR:	SAMRA, RAJVINDER K		FACILITY TYPE:	740
ADDRESS:	501 SOUTH APRICOT AVE		TELEPHONE:	(559) 598-9515
CITY:	FRESNO	STATE: CA	ZIP CODE:	93727
CAPACITY:	6	CENSUS: 5	DATE:	08/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Staff- Rogelio Negrete		TIME COMPLETED:	12:15 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 8/17/2024 Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct an annual inspection. LPA introduced herself to Direct Care Staff Rogelio Negrete and explained the purpose of the visit, LPA was granted entrance into the facility, and Licensee/Administrator Rajvinder Samra was contact and informed of the reason of the unannounced visit. Licensee/Administrator stated they would not be able to attend the annual inspection. LPA toured the facility inside and out including kitchen, dining, living room, bedrooms, bathrooms, and exterior. LPA observed the facility to be at a comfortable temperature, clutter free and odor free. LPA observed exit passageways to be clear however LPA observed the exit from the master bedroom to be stuck and difficult to open, and the exit door inside the garage to be stuck and difficult to open. This creates an obstruction of the exits. Facility has 2 residents with a diagnosis of dementia, the exits did not have an audio alarm on the exits. Emergency phones numbers were observed in the facility. Facility capacity is 6, with a current census of 5. Facility has 4 bedrooms and 3 bathrooms. Resident’s share bedrooms. Facility has live-in staff which have their own bedroom and bathroom which are kept locked an inaccessible to residents. Fire extinguishers were observed to be last serviced on 6/7/2024 and are in good standing with charge. Smoke detectors and carbon monoxide detectors were tested and are in working condition. Water temperature was checked in a shared bathroom between resident bedrooms and read at 105.6 degrees Fahrenheit. Water was also checked in the kitchen which read at 105.4 degrees Fahrenheit.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna Miranda	TELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2024

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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BLOSSOM CREEKS ASSISTED LIVING	FACILITY NUMBER: 107206795
	VISIT DATE: 08/17/2024

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Inspecting kitchen LPA did not observed the required 7-day supply of non-perishable food or 2- day supply of fresh perishables food items to be properly stored. LPA observed insects throughout the kitchen. Knives & cleaning supplies were observed to be locked and inaccessible to residents.

LPA is requesting the following documents be submitted to the Fresno CCL office by 08/30/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Personnel Report (LIC500), Register of Facility Clients/Residents (LIC9020A).

A follow-up visit will be conducted at a later date to review resident files, staff files, and other documents. The documents were not available at this time due to Licensee/Administrator not available and documents not being kept at the facility or staff not having access. Deficiencies will be cited at the follow-up visit.

Exit interview was conducted and a copy of this report LIC809 was provided to Staff Rogelio Negrete.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna Miranda	TELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2024

LIC809 (FAS) - (06/04)

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