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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603258
Report Date: 03/23/2022
Date Signed: 03/23/2022 01:25:19 PM


Document Has Been Signed on 03/23/2022 01:25 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:BLOSSOM VALLEY OASIS, LLCFACILITY NUMBER:
198603258
ADMINISTRATOR:DHYLVA MARTINEZ-METZLERFACILITY TYPE:
740
ADDRESS:975 ASBURY AVETELEPHONE:
(909) 450-6962
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY:6CENSUS: 2DATE:
03/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Facility Administrator/S-1TIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices. LPA met with Facility Administrator and discussed the purpose of today's visit.

This home consists of (4) bedrooms, (2 1/2) restrooms, kitchen, dinning area, living room and attached garage. There are currently (2) Residents residing at this facility. During today's visit, LPA was informed by Facility Administrator that operation of this facility will cease by 03/27/2022. LPA requested Facility Administrator to submit a closure letter, relocation information (for both Residents) and the original Community Care Licensing Division-Adult and Senior Care License to LPA.

The following were observed/inspected: .
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility and throughout the facility.
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • PPE supplies observed.
  • Restrooms have electric hand soap and paper towel dispensers and hand sanitizer.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.
  • Medication is locked inside the medication cabinet located in the dinning room area.
  • Residents were be socially distanced according to local public health guidelines.
  • Staff responsible for direct care and supervision will wear masks.

Exit interview conducted, a copy of this report and Appeal Rights were provided to S-2. Note: LPA was experiencing technical difficulties during today's visit.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2022
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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