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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604527
Report Date: 06/21/2023
Date Signed: 06/21/2023 04:48:57 PM


Document Has Been Signed on 06/21/2023 04:48 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:GOLDEN BLOOM VILLAFACILITY NUMBER:
374604527
ADMINISTRATOR:VALENCIA, LIZAFACILITY TYPE:
740
ADDRESS:725 GOLDEN LANETELEPHONE:
(562) 348-2388
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY:6CENSUS: 0DATE:
06/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Liza ValenciaTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Jacqueline Shaw Ross arrived to the facility and was met by Licensee Liza Valencia to conduct the Annual Inspection. LPA advised Licensee the purpose of the visit.

The facility has been licensed from June 7, 2022 to present with no clients in care and one staff present.

The facility is a four (4) bedroom three (3) bathroom home. Currently the resident/client living area of this facility is solely permitted in the central and East portions of the home. Licensee informed LPA that she has two extra rooms available and would like to increase the capacity from six (6) clients to eight (8) clients. LPA advised Licensee to formally submit a letter of request to increase the capacity along with a current copy of the facility sketch.

LPA made observation throughout the remaining tour of the interior and exterior of the facility inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations.Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are newly installed. Water temperature was tested at 114.2 degrees Fahrenheit. All four (4) bedrooms are fully furnished. The facility is fully furnished, clean and with no odors. Kitchen is currently stocked with appropriate food supplies. LPA reviewed facility files and records. Background clearances and trainings were current. Additional staff present was not available for an interview.

No deficiencies were observed during today's annual inspection.

This LIC 809 was reviewed with and a copy provided to the Licensee, Liza Valencia.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw RossTELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2023
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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