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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002874
Report Date: 06/23/2022
Date Signed: 06/23/2022 11:50:05 AM

Document Has Been Signed on 06/23/2022 11:50 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:BLUE SPRINGS HOMEFACILITY NUMBER:
345002874
ADMINISTRATOR:LU, ANYANGFACILITY TYPE:
735
ADDRESS:7007 BLUE SPRINGS WAYTELEPHONE:
(415) 898-3690
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY: 4CENSUS: 0DATE:
06/23/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Anyang Lu, AdministratorTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Michael Hood met with applicant, Anyang Lu, to conduct a Pre- Licensing visit. The facility has a fire clearance for 4 ambulatory clients. Applicant holds a current administrator certificate (#6044560735 with expiration date 12/30/2023).

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are three (3) bedrooms and two (2) bathrooms for client use, along with one (1) bedroom for staff. LPA observed facility to be properly furnished, including appropriate bedding and lighting in bedrooms. Bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 119 degrees F.

LPA checked the kitchen area for the ability to prepare and store food. LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to clients. LPA observed smoke detectors and carbon monoxide detectors at the care home to be operational. Fire extinguisher and first aid kit are maintained and ready for emergency use.

Pre-licensing passed and Component III completed. Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations. Application is pending and LPA will forward findings to the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application. A copy of this report was provided to the facility. Exit interview conducted.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2022
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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