331881088-10-17-2023-56-AS-ACON-CWPTYC-20231017150830

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881088
Report Date: 10/17/2023
Date Signed: 10/17/2023 03:08:36 PM

Document Has Been Signed on 10/17/2023 03:08 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	BLOSSOM GRACE		FACILITY NUMBER:	331881088
ADMINISTRATOR:	WILWAYCO, ROLANDO		FACILITY TYPE:	735
ADDRESS:	472 ALDER LANE		TELEPHONE:	(858) 610-0594
CITY:	BANNING	STATE: CA	ZIP CODE:	92220
CAPACITY: 4		CENSUS: 2	DATE:	10/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Cynthia & Rolando Waywilco, Administrators		TIME COMPLETED:	03:15 PM

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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Blossom Grace Facility unannounced to conduct the Annual Inspection. LPA was greeted and granted entry by, Administrator, Cynthia Waywilco. LPA also met, Administrator, Rolando Waywilco. LPA was provided space to work and then accompanied on a walk through of the facility.

The facility is comprised of 5 Bedrooms, (2 Staff Rooms & 3 Resident Rooms) 3 Bathrooms, Living Room, Dining Area, Kitchen, Laundry Room, backyard and attached garage. The facility is an Adult Residential Facility (ARF) also vendorized by the Inland Regional Center, designated Level 3. Administrator reports there are two, (2) residents present and 2 residents at their day program at time of visit.

LPA was accompanied by Administrators, Rolando and Cynthia Waywilco to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). Pathways interior and exterior were clutter free and unobstructed. The facility is maintained in comfortable temperature. The facility is equipped with functional smoke detectors and carbon monoxide alarms. Extra linens, hygiene supplies, toilet paper and towels were found in a hallway closet in sufficient amounts. Administrator reports fire/disaster drills are conducted on a monthly basis. Last drill conducted September 2023.

LPA observed resident rooms, each room included a bed with required linens, sufficient storage, furniture, lighting and seating. Additionally all rooms appeared neat and orderly. LPA also observed night-lights plugged in throughout the facility. LPA observed sufficient furniture and adequate seating in the living and dining rooms. The hot water temperature tested and found within regulation. LPA observed posters for resident rights, Long Term Care Ombudsman, licensing complaint, LET-US-KNOW and Infection Control posted in common areas of the facility. Cleaning supplies, toxins, sharps, and other dangerous items were kept secure in the attached garage. The resident's medication records and medications are kept secure in a kitchen cabinet. Resident, Facility and Staff files are kept secure within a file cabinet. Please see LIC809-C

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BLOSSOM GRACE	FACILITY NUMBER: 331881088
	VISIT DATE: 10/17/2023

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Food Service: LPA observed a pantry and cabinets well stocked with canned goods, snacks and dry foods in good standing. LPA observed the facility refrigerator stocked with milk, eggs, break, water and juices. Sufficient amounts of both perishable and non-perishable food for the number of residents in care. Dishes, cups, and utensils were also observed and stored properly. LPA observed a fully charged fire extinguisher, last inspected December 2022; near the kitchen Emergency Supplies of food, water, batteries, PPE were located secure in the garage.

Records: LPA reviewed 2 resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed 1 staff file for First Aid/CPR certification, criminal record clearance, training, and health screenings. Each file was found to have all required licensing documents.

Overall, LPA observed that the facility is neat, orderly, in good repair, and operating in safe conditions for residents in care.

Based on observations, interviews and record reviews no deficiencies will be cited per Title 22, California Code of Regulations. A copy of this report was read/reviewed with Facility Representative; signature acknowledges understanding and receipt of report and attachments.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

LIC809 (FAS) - (06/04)

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