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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800071
Report Date: 07/15/2022
Date Signed: 07/15/2022 04:00:52 PM


Document Has Been Signed on 07/15/2022 04:00 PM - It Cannot Be Edited

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
, 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: 49DATE:
07/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:48 PM
MET WITH:Administrator Susiani Halium.TIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Bernadette Allen 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, Allen arrived at the facility at 2:48 PM and was greeted and granted entry into the facility. LPA was required to take a antigen covid-19 test per Administrator, Susiani Halium. The administrator confirmed that there are currently no cases/exposures of COVID-19 in the facility.

During today's visit, LPA toured the facility and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer).

The facility staff has a plan to manage Covid-19 symptoms, which includes staff monitoring residents regularly for any changes in condition, which includes daily temperature checks. The facility will contact the resident's physician should there be event of any COVID-19 related illnesses. The facility staff are responsible for cleaning and disinfecting the highly touched surfaces during their shift.

LPA toured the facility inside and out and there were no health and safety concerns.

The outdoor and indoor hallways were also free of obstruction. The client rooms had the required furniture and sufficient lighting. The bathrooms can accommodate the needs for bathing and showers and have non-slip flooring. LPA observed staff wearing face mask and hand sanitizer throughout the facility.

The facility has charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors.

Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and a copy of this report was provided to Administrator Susiani Halium.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2022
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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