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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881088
Report Date: 08/24/2021
Date Signed: 08/24/2021 09:22:25 AM

Document Has Been Signed on 08/24/2021 09:22 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BLOSSOM GRACEFACILITY NUMBER:
331881088
ADMINISTRATOR:WILWAYCO, ROLANDOFACILITY TYPE:
735
ADDRESS:472 ALDER LANETELEPHONE:
(858) 610-0594
CITY:BANNINGSTATE: CAZIP CODE:
92220
CAPACITY: 4CENSUS: 4DATE:
08/24/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Rolando and Cynthia Wilwayco, LicenseesTIME COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) Deborah Mullen conducted an announced pre-licensing inspection. LPA met with licensees, Rolando and Cynthia Wilwayco. The facility is currently licensed and has 4 residents in care. The new licensed will be for 4 ambulatory residents.

LPA inspected the home both inside and out. The home has five bedrooms, three and a half baths, a living room, dining room and kitchen. The bedrooms are furnished with a bed, dresser, night stand and light for residents use. Bathrooms were observed to be safe, sanitary, and in operating condition with grab bars for clients as needed. LPA observed ample amounts of towels and linens for residents. LPA observed there to be ample food supply for residents in care. Disinfectants, cleaning solutions, poisons are inaccessible to clients and located under the sink in the kitchen, in the laundry room, and in the garage. The sharp knives and scissors are kept locked under the kitchen sink. The smoke alarms and carbon monoxide detector were tested and are in working order. The medications were locked and stored in a kitchen cabinet and are inaccessible to residents. There are no firearms, dangerous weapons, pools or bodies of water on the property. The licensees are both certified administrators, with their certifications expiring on 9/4/2022 and 11/4/2022. Infection control practices and procedures were observed to be in use by the licensees.

The facility is in compliance with Title 22 regulations and is approved for licensure. An exit interview was conducted and a copy of this report was reviewed with and given to Mr. and Mrs. Wilwayco.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Deborah Mullen
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2021
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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