331881672-2-4-2026-18-AS-IVAZ-DQZ2Y2-20260204164800

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881672
Report Date: 02/04/2026
Date Signed: 02/04/2026 04:49:16 PM

Document Has Been Signed on 02/04/2026 04:49 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	BLOSSOM HOME CARE		FACILITY NUMBER:	331881672
ADMINISTRATOR/ DIRECTOR:	IBACH, GIANNA M		FACILITY TYPE:	740
ADDRESS:	28492 PEAR BLOSSOM LANE		TELEPHONE:	(951) 455-5755
CITY:	MORENO VALLEY	STATE: CA	ZIP CODE:	92555
CAPACITY: 6		CENSUS: 4	DATE:	02/04/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:02 PM
MET WITH:	Administrator Gianna Ibach		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

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	On 2/4/2026, Licensing Program Analyst (LPA) Imaculada Vasquez, Valerie Flores, and Aziz Faizi conducted an unannounced 1-year required visit. LPA's were greeted and granted entry into the facility by care staff Natalie Sumolang. LPA's conducted a tour of the facility alongside Natalie. During the visit, LPA's observed the following: The physical plant is a single-story structure which consisted of (4) four resident bedrooms, (2) two bathrooms, living room, dining area, laundry room, garage and backyard. Resident bedrooms were equipped with the required bedding, furniture, and functional lighting. Bathroom were observed; toilets and shower areas were observed to be equipped with the required grabs. Showers also maintained slip-resistant materials. LPA's observed games and other activities located in the living room. Indoor and outdoor passageways were observed to be free of obstruction. The facility operates laundry services on-site. Soaps and other disinfectants were observed to be stored in a locked cabinet. The kitchen was observed to be organized and sanitary. LPA's observed a locked cabinet which stored knives and other sharp materials. The facility maintained a (2) two-day supply of perishable foods and a (7) seven-day supply of non-perishable foods. An activity calendar was observed to be posted and current. Emergency food and water were observed to be stored in the garage. Backyard was observed to have a covered patio that was furnished. LPA's observed the required postings of the PUB475, LTCO, license, facility sketch, personal rights, and current Administrator Certification. (2) Two staff files were reviewed. Staff review included but not limited to personnel records, health screenings, TB results, and relevant training's. (3) Three out of (4) four resident files were review. Records reviewed included but not limited to admission agreements, preplacement appraisals, appraisals, medical assessment, and current medication list. An exit interview was conducted and a copy of this report was provided to Administrator.

NAME OF LICENSING PROGRAM MANAGER: Carolyn Tuba
NAME OF LICENSING PROGRAM ANALYST: Imaculada Vasquez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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