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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208882
Report Date: 12/19/2023
Date Signed: 12/20/2023 04:13:54 PM


Document Has Been Signed on 12/20/2023 04:13 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:BLOSSOM HAVEN, INC.FACILITY NUMBER:
107208882
ADMINISTRATOR:JALAO, LY SYFACILITY TYPE:
740
ADDRESS:6618 E HARWOOD AVETELEPHONE:
(559) 458-1958
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY:6CENSUS: 3DATE:
12/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Sy Ly, AdminstratorTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Lissett Padgett arrived unannounced to conduct the Annual inspection. LPA was granted entry to the facility by Staff (S1). S1 called Administrator Sy Ly (AD) who arrived shortly thereafter and LPA explained the purpose of the visit.

During this visit, LPA and AD toured the facility. The facility has a current census of 3. Resident rooms contained required furnishings and lighting. LPA observed required items in bathrooms with hot water measuring at 114.5 degrees F. Resident hygiene supplies were properly stored and available. The kitchen was toured observed in good repair with necessary items and appliances and sharps/knives were properly stored. LPA observed required emergency food supply and paper products. Medications are centrally stored and locked in pantry. Doors and passageways are unobstructed throughout the facility including outdoors. Facility has two First Aid kits, they are located in the kitchen pantry and were found to contain required items. Sufficient supply of perishable and non-perishable food observed.
Fire Extinguisher is located on kitchen counter and was serviced on 12/5/2023. Smoke and Carbon Monoxide detectors are tested and found to be operational. LPA conducted resident and staff file reviews and interviews.

Technical violations are being cited in accordance with California Code of Regulations.

An exit interview was conducted and a Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with Administrator, whose signature on this form confirms receipt of these documents.

LPA is requesting the following documents be submitted to the Fresno CCL office by 12/29/23:Copy of property grant deed, Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett PadgettTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2023
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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