<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700257
Report Date: 05/03/2023
Date Signed: 05/03/2023 02:50:48 PM


Document Has Been Signed on 05/03/2023 02:50 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



FACILITY NAME:BLOSSOM VALE SENIOR LIVINGFACILITY NUMBER:
342700257
ADMINISTRATOR:DANIELLE SHANKLINFACILITY TYPE:
740
ADDRESS:6125 HAZEL AVENUETELEPHONE:
(916) 988-7901
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:120CENSUS: 88DATE:
05/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Danielle ShanklinTIME COMPLETED:
03:15 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
Licensing Program Analysts (LPAs) Talwinder Bains and Melissa Parks arrived on Wednesday May 3, 2023 to conduct the annual inspection. LPAs wore a surgical masks during todays visit.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPAs reviewed resident (9) and staff (9) files. All resident files contained the required paperwork. All staff files contained the required paperwork and training.

LPAs and Maintenance director Ivan Estrada toured the facility together to ensure the health and safety of residents in care. The areas toured included resident apartments, lobby, cafe, kitchen, and courtyard. LPAs observed the facility's emergency food and water storage and PPE storage. In the areas toured, there were no health or safety violations observed.

LPAs requested the facility to update their LIC500, facility roster, LIC610E and current liability insurance and submit to the Department by 5/17/2023.

No deficiencies cited. Exit interview conducted. A copy of this report was emailed to the Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa ParksTELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1