361800071-9-22-2023-56-AS-MMAE-CVWVKJ-20230922163025

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361800071
Report Date: 09/22/2023
Date Signed: 09/22/2023 04:31:12 PM

Document Has Been Signed on 09/22/2023 04:31 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	BLOSSOM GROVE ALZHEIMER'S SPECIAL CARE CENTER		FACILITY NUMBER:	361800071
ADMINISTRATOR:	SUSIANI HALIUM		FACILITY TYPE:	740
ADDRESS:	11116 NEW JERSEY ST		TELEPHONE:	(909) 335-6660
CITY:	REDLANDS	STATE: CA	ZIP CODE:	92373
CAPACITY:	66	CENSUS: 58	DATE:	09/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Susiani Halim, Executive Director		TIME COMPLETED:	04:30 PM

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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Susiani Halim, Executive Director and discussed the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE). Licensed capacity is (66) . The current census is (58). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

LPA inspected the facility inside and out. Indoor and outdoor passageways were kept free of obstruction. The facility has sufficient lighting and is maintained at a comfortable temperature.

LPA inspected the kitchen. Facility has sufficient non-perishable and perishable food for the number of clients in care. Menus are posted in various areas of the facility. Facility food is stored in a safe and healthful manner. Sharps are stored and kept locked and inaccessible to clients in care.

LPA inspected (5) client bedrooms. Bedrooms are equipped with: beds, nightstands, chairs, sufficient linen and lighting.

LPA inspected (5) client bathrooms. Bathrooms are operating in safe and sanitary conditions. The hot water temperatures tested between 105 and 110 degrees F.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BLOSSOM GROVE ALZHEIMER'S SPECIAL CARE CENTER	FACILITY NUMBER: 361800071
	VISIT DATE: 09/22/2023

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The facility is equipped with operating carbon monoxide alarms and operating telephone service. Posters such as personal rights, Complaint reporting, the disaster plan were posted in a common area. An Emergency drill was conducted on 09/01/23.

All client medications were administered as prescribed and kept locked inaccessible to clients in care.

All staff files reviewed had criminal record clearance, training, and health screenings. All client records reviewed had admissions agreements, physician's report, and assessments.

An exit interview was conducted, where this report was discussed and a copy of report with appeal rights was provided to the Executive Director at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC809 (FAS) - (06/04)

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