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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700257
Report Date: 04/26/2022
Date Signed: 04/26/2022 02:07:34 PM


Document Has Been Signed on 04/26/2022 02:07 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, 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: 72DATE:
04/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:34 PM
MET WITH:Danielle Shanklin, AdministratorTIME COMPLETED:
02:35 PM
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On April 26, 2022, at 1:30pm, (LPA) De Anna Williams-Lyons made an unannounced visit to conduct facilities required annual inspection. LPA Lyons met with whose Danielle Shanklin, Administrator and informed her the reason for the visit. Her administrators certificate expires 7/24/2023.

Prior to the visit, LPA 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; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks.

Danielle and LPA completed the infectious Control questionnaire with no issues to report,

The last Fire extinguisher check was 3/10/2022.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed during this visit.

The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610D the Emergency Disaster Plan, and copy of current Liability Insurance to update the facility file in our regional office. Administrator shall submit the listed documents to Licensing no later than May 26, 2022.

An exit interview was conducted and a copy of this report was given to Danielle.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-LyonsTELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2022
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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