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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345003021
Report Date: 08/29/2023
Date Signed: 08/29/2023 10:26:46 AM


Document Has Been Signed on 08/29/2023 10:26 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 1FACILITY NUMBER:
345003021
ADMINISTRATOR:TRIPADUSH, ALENAFACILITY TYPE:
740
ADDRESS:8934 VAN MOORE LANETELEPHONE:
(916) 578-9821
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 5DATE:
08/29/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator ,Raluca SolovyevTIME COMPLETED:
10:45 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
On 08/29/23, Licensing Program Analyst (LPA) Talwinder Bains met with administrator ,Raluca Solovyev , to conduct an Pre- Licensing visit. This application is a change in ownership (CHOW) . This address is currently licensed as Friendly Care Home, Facility # 342700567 . Administrator holds a current administrator certificate (# 6055623740 with expiration date 03/08/24 ). The facility currently has 5 residents during today's inspection. Facility has been approved for 6 non ambulatory residents.

LPA toured the facility with administrator. LPA toured residents bedrooms and they were properly furnished and maintained. LPA toured common bathrooms and observed to be clean and sanitary. The food supply is within compliance, 2 days of perishable and 7 days’ worth of non-perishable food items. Smoke detectors are operational. There are carbon monoxide detectors which are functioning. The Fire extinguisher was charged, serviced (01/04/23) and functional. Grab bars were present at the toilet and in the shower. All exits were unobstructed. All toxins, medications, and sharps were locked and stored away. The disaster drill is current. Facility's temperature was 73F during inspection. Hot water temperature was observed to be 110 degrees F, which is within the regulation range of 105-120 degree. First aid kit found to be complete.

LPA reviewed 1 sample file for 1 resident and for 1 staff and found out that all required paperwork was present . Component III was waived as the current administrator has been administrator for other RCFEs licensed by CCLD . LPA will forward findings to the Centralized Application Bureau (CAB) that facility met all the pre-licensing components.

Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations on today's pre-licensing inspection. A copy of this report was provided to the facility. Exit interview conducted.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023
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