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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920078
Report Date: 03/04/2024
Date Signed: 03/04/2024 11:06:35 AM


Document Has Been Signed on 03/04/2024 11:06 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 VALE SENIOR LIVINGFACILITY NUMBER:
345920078
ADMINISTRATOR:SHANKLIN, DANIELLEFACILITY TYPE:
740
ADDRESS:6125 HAZEL AVENUETELEPHONE:
(760) 547-2863
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:120CENSUS: 92DATE:
03/04/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Administrator, Danielle ShanklinTIME COMPLETED:
11:20 AM
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On 03/04/24, Licensing Program Analyst (LPA) Talwinder Bains met with administrator Danielle Shanklin, to conduct an Pre- Licensing visit. This application is a change in ownership (CHOW) . This address is currently licensed as ,BLOSSOM VALE SENIOR LIVING, Facility # 342700257. Administrator holds a current administrator certificate (# 6057022740 with expiration date 07/24/2025). The facility currently has 92 residents during today's inspection. Facility has Fire Clearance for 120 residents of which 108 can be non-ambulatory and 12 can be bedridden( rooms 101-157 only) from date Fire Inspection date- 02/07/24.

LPA toured the facility with administrator. LPA toured 2 sample 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 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.

Component III was waived as the current administrator has been administrator for other RCFE 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: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2024
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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