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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700462
Report Date: 07/15/2021
Date Signed: 07/15/2021 03:53:40 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 RESIDENTIAL CARE HOMEFACILITY NUMBER:
342700462
ADMINISTRATOR:TRIPADUSH, ALENAFACILITY TYPE:
740
ADDRESS:6604 WOODMORE OAKS DRTELEPHONE:
(916) 578-9821
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 5DATE:
07/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Alena Tripadush, administratorTIME COMPLETED:
04:05 PM
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Licensing Program Analysts (LPA) Wolter arrived at the facility unannounced on 07/15/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with staff Mahaida McGregor and explained the purpose of the visit. Staff contacted administrator Alena Tripadush and informed her of LPAs presence, administrator arrived shortly after LPAs arrival.

Prior to initiating the annual inspection 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, and contacted facility 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: surgical mask. Additionally, LPA was screened by facility staff upon entry.

LPA and administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathrooms, staff room, kitchen, garage, and outdoor area. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA and administrator completed the infection control domain together 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.

Administrator 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 07/22/2021.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Danyle WolterTELEPHONE: (916) 708-5307
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2021
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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