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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700257
Report Date: 01/25/2023
Date Signed: 01/25/2023 11:15:31 AM


Document Has Been Signed on 01/25/2023 11:15 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: 88DATE:
01/25/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Danielle Shanklin, AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 01/25/2023 to conduct a case management inspection to follow up on a recent AWOL at the facility. LPA met with Danielle Shanklin, Administrator and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, the 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. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn surgical mask.

The facility submitted a completed Unusual Incident/Injury Report (LIC624) on/around 12/28/22 regarding resident (R1) leaving the facility unattended on 12/21/22, at approximately 5.00pm. On 12/21/22 around 5pm, facility was notified by R1s son that R1 was at Bank of America location next to facility as reported by Sheriff department to R1s son. Facility staff followed up immediately after the AWOL and found R1 at bank location next to facility. Resident returned to the facility uninjured. Facility notified R1 doctor and family on 12/21/22 regarding this AWOL incident.

R1's physician's report, dated 01/21/22, indicates that resident has diagnosis of dementia with behavior disturbance and cannot leave the facility unassisted. This was first AWOL incident for R1 since R1s admission to the facility. Resident has not tried to leave facility again and has been communicating better with the staff if R1 needs something.

No deficiencies were cited during today's visit.
Exit interview conducted and copy of the report left at the facility.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023
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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