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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002874
Report Date: 07/17/2024
Date Signed: 07/17/2024 09:38:48 AM

Document Has Been Signed on 07/17/2024 09:38 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:BLUE SPRINGS HOMEFACILITY NUMBER:
345002874
ADMINISTRATOR/
DIRECTOR:		LU, ANYANGFACILITY TYPE:
735
ADDRESS:7007 BLUE SPRINGS WAYTELEPHONE:
(415) 501-9638
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY: 4CENSUS: 0DATE:
07/17/2024
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator- Anyang LuTIME VISIT/
INSPECTION COMPLETED:
09:45 AM
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On 07/17/2024, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility announced to conduct a Required-1 Year Inspection. LPA met with Administrator, Anyang Lu, to conduct the visit. There are currently no residents at the facility. Administrator stated they have a meeting with ALTA regional center at the end of the month for the next steps that need to be taken to become vendorized.

LPA and administrator toured the interior and exterior of the facility. Areas toured include but are not limited to: common areas, three (3) 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 115 degrees Fahrenheit which is within the required range of 105 to 120 degrees Fahrenheit. LPA observed fire detectors and carbon monoxide alarms to be operable. The fire extinguisher was last serviced on 07/03/2023. Administrator has an appointment this week to get fire extinguisher serviced. 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: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
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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