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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700462
Report Date: 01/06/2025
Date Signed: 01/06/2025 11:02:48 AM

Document Has Been Signed on 01/06/2025 11:02 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BLOSSOM RESIDENTIAL CARE HOMEFACILITY NUMBER:
342700462
ADMINISTRATOR/
DIRECTOR:		TRIPADUSH, ALENAFACILITY TYPE:
740
ADDRESS:6604 WOODMORE OAKS DRTELEPHONE:
(916) 578-9821
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
01/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH: Administrator, Alena TripadushTIME VISIT/
INSPECTION COMPLETED:
11:15 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
Licensing Program Analyst (LPA) Talwinder Bains arrived on 01/06/25 to conduct the annual inspection.
LPA met with administrator, Alena Tripadush and explained the reason for today's visit.

During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed residents (2) and staff files (2). All residents files contained the required paperwork. Staff file contained the required paperwork. Staff have current first aid and CPR training. Facility was clean. All required postings were observed. LPA reviewed medications of 2 residents comparing with physician orders.

LPA and administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included residents rooms, bathrooms, kitchen, common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. All exits were unobstructed. There is a gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked . LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguisher is ready for emergency use . Inside temperature was observed to be 74 degree F.

LPA requested a copy of the LIC500, LIC610E and current liability insurance to be sent to the Department by 01/20/25.

Deficiencies were observed and cited per Title 22, CCR Regulations as listed on LIC 809-D. Civil penalties shall be assessed if facility does not comply with POC requirements which were issued today. Exit interview conducted. Copy of this report and appeal rights were provided.
Laura MunozTELEPHONE: (916) 263-4743
Talwinder BainsTELEPHONE: (916) 263-4700
DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2025
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 3
Document Has Been Signed on 01/06/2025 11:02 AM - It Cannot Be Edited


Created By: Talwinder Bains On 01/06/2025 at 10:48 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BLOSSOM RESIDENTIAL CARE HOME
FACILITY NUMBER: 342700462

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as water temperature was measured between 137-140 degree F during today's visit, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2025
Plan of Correction
1
2
3
4
Licensee/Administrator shall enure that the water temperature will be regulated between 105-120 degree F as required per this Regulation. Facility shall do weekly water check temperature and send Log to Department for review by POC date-02/05/25. Department may conduct a POC visit to clear this citation.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Laura Munoz
TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME:Talwinder Bains
TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3