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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800071
Report Date: 08/23/2021
Date Signed: 08/23/2021 02:44:01 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BLOSSOM GROVE ALZHEIMER'S SPECIAL CARE CENTERFACILITY NUMBER:
361800071
ADMINISTRATOR:SUSIANI HALIUMFACILITY TYPE:
740
ADDRESS:11116 NEW JERSEY STTELEPHONE:
(909) 335-6660
CITY:REDLANDSSTATE: CAZIP CODE:
92373
CAPACITY:66CENSUS: 54DATE:
08/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Administrator, Susiani HaliumTIME COMPLETED:
02:43 PM
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Licensing Program Analyst's (LPA) Elecia Weathersby made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA Weathersby arrived and was greeted and granted entry by the Administrator, Susiani Halium. The administrator confirmed that there are currently no cases/exposures of COVID-19 in the facility.

During the inspection, LPA Weathersby conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. The facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a 30+ day supply of Personal Protective Equipment (PPE). LPA Weathersby also observed that all staff members were properly fitted with face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining clients, and properly caring for clients with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the client presents any COVID-19 symptoms.

LPA Weathersby observed no health and safety concerns at the time of visit. Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code or Regulations. An exit interview was conducted where this report was discussed, and a copy of this report was also provided to Administrator, Susiani Halium at the conclusion of the inspection.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Elecia WeathersbyTELEPHONE: (951) 255-9516
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021
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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