<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209300
Report Date: 01/26/2024
Date Signed: 01/26/2024 09:51:47 AM


Document Has Been Signed on 01/26/2024 09:51 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:BLOSSOM CREEKS ASSISTED LIVING 2 INC.FACILITY NUMBER:
107209300
ADMINISTRATOR:SAMRA, RAJVINDERFACILITY TYPE:
740
ADDRESS:2770 NORTH BURGAN AVENUETELEPHONE:
(559) 598-9515
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY:6CENSUS: 0DATE:
01/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:13 AM
MET WITH:Rajvinder Samra, AdministratorTIME COMPLETED:
09:55 AM
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
Licensing Program Analyst (LPA) Lissett Padgett arrived unannounced to conduct the Annual inspection. LPA met with Administrator Rajvinder Samra (AD) and explained the purpose of the visit. Facility was toured with AD.
During this visit, LPA toured the facility inside & out. There are no residents currently residing in this facility. LPA observed required items in bathrooms with hot water measuring 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 stored in lockable drawer. LPA observed required food supply, including emergency food buckets and paper products. AD has a dedicated cabinet for medications and a lock box for refrigerated medications.
Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors. First aid kit located in kitchen cabinet and found to contain required items.
Two fire extinguishers located in facility (hallway and kitchen) and were serviced in Dec 2022. Smoke and Carbon Monoxide detectors were tested and found to be operational. Administrator’s re-certification was confirmed to be in active status.
AD is requesting 1 bedridden room Fire Clearance. LPA will submit necessary paperwork.

A copy of this report and exit interview conducted with AD.

LPA is requesting the following documents be submitted to the Fresno CCL office by 2/9/2024. 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).
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Lissett PadgettTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1