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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700257
Report Date: 05/18/2021
Date Signed: 05/18/2021 02:33:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:BLOSSOM VALE SENIOR LIVINGFACILITY NUMBER:
342700257
ADMINISTRATOR:GOETZ, ASHLEYFACILITY TYPE:
740
ADDRESS:6125 HAZEL AVENUETELEPHONE:
(916) 988-7901
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:120CENSUS: 70DATE:
05/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Ashley Goetz, Executive DirectorTIME COMPLETED:
02:45 PM
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Licensing Program Analysts (LPAs) Wolter and Leitzell arrived at the facility unannounced on 05/18/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPAs met with Executive Director, Ashley Goetz and explained the purpose of the visit. Prior to initiating the annual inspection, LPAs completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted facility and completed a facility risk assessment. LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally, LPAs were screened by facility staff upon entering the facility.

LPAs and Executive Director toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, three (3) occupied resident rooms, two (2) empty rooms, kitchen, med room, activity room, two (2) common bathrooms and outdoor area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPAs and Executive Director completed the infection control domain and facility was found to be in substantial compliance at this time.

No deficiencies are being cited as a result of todays inspection.
Exit interview conducted and copy of report left at the facility.

Executive Director to send in updated copy of LIC 308 - Designation of Facility Responsibility, LIC 500 - Personnel Report, and current copy of Liability Insurance to Community Care Licensing by 05/25/2021.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021
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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