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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700462
Report Date: 01/12/2022
Date Signed: 01/13/2022 02:34:55 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: 4DATE:
01/12/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Latoya LewisTIME COMPLETED:
11:30 AM
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
Unannounced annual visit utilizing the infection control domain was performed by LPA Michael Smith. Contact with Alena Tripadush.

A review of staff records on 1/12/22 indicates that all facility staff and other individuals who require caregiver background checks have received criminal record clearances.

As a result of this visit, there were no deficiencies or technical violations.

Exit interview conducted.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael SmithTELEPHONE: (916) 208-7807
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
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