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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002874
Report Date: 07/07/2023
Date Signed: 07/07/2023 11:33:34 AM

Document Has Been Signed on 07/07/2023 11:33 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, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME:BLUE SPRINGS HOMEFACILITY NUMBER:
345002874
ADMINISTRATOR:LU, ANYANGFACILITY TYPE:
735
ADDRESS:7007 BLUE SPRINGS WAYTELEPHONE:
(415) 501-9638
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY: 4CENSUS: 0DATE:
07/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator: Anyang LuTIME COMPLETED:
11:45 AM
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On 07/07/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Required-1 Year Inspection. LPA met with Administrator, Anyang Lu, and explained the purpose of the visit. There are currently no residents at the facility.

LPA and administrator toured the interior and exterior of the facility. Areas toured include but are not limited to: common areas, residents' bedrooms, bathrooms, kitchen, garage and backyard. LPA observed required furniture, and lighting throughout the residents' bedrooms and facility. LPA observed residents' bathrooms to be clean, sanitary, and in good repair. The hot water temperature was measured in the kitchen at 117 degrees Fahrenheit. LPA observed fire detectors and carbon monoxide alarms to be operable. The fire extinguisher was last serviced on 07/03/2023. LPA observed required Licensing posters posted throughout the facility. First aid kit was completed.

No deficiencies being cited during today's inspection.

Exit interview conducted and report provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2023
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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