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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700257
Report Date: 06/28/2022
Date Signed: 06/28/2022 10:23:14 AM


Document Has Been Signed on 06/28/2022 10:23 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, 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: 75DATE:
06/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Health & Wellness Director- Chrystal Perez TIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Case Management- Incident visit. LPA met with Health and Wellness Director (HWD), Chrystal Perez, and explained the purpose of the visit. Prior to entering the facility, the following Personal Protective Equipment (PPE) was worn: Surgical Mask.

The purpose of the visit was to follow-up on an unusual incident/injury report that was sent to Community Care Licensing (CCL) on 06/23/2022. The report indicates that a resident (R1) was found sitting in the courtyard by staff (S1). R1 was off baseline, sweating, warm to the touch. S1 assisted R1 to a cool area and place cold compression on R1 to cool R1 down.

The interview with HWD indicated R1 was out in the courtyard for about two (2) hours. R1 was found at approximately 4 PM by S1 who observed R1 was off baseline. HWD stated paramedics were called and arrived at the facility. HWD stated when paramedics arrived at the facility R1 was responsive and back to baseline and was transferred to Hospital for further evaluation.

LPA requested for R1’s physician’s report, needs & services plan, charting notes, and medical discharge documents. LPA interviewed S1. LPA toured the facility together with HWD to ensure health and safety of residents in care. In the areas toured no immediate health, safety, or personal rights violations were observed.

At this time, deficiencies are not being cited.

Exit interview conducted and a copy of the report left at the facility
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022
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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