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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604527
Report Date: 03/22/2024
Date Signed: 03/22/2024 11:37:18 AM


Document Has Been Signed on 03/22/2024 11:37 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
CCLD Regional Office, 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: 3DATE:
03/22/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:ADMINISTRATOR, LIZA VALENCIATIME COMPLETED:
11:48 AM
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On March 22, 2024, Licensing Program Analysts (LPA), Venus Mixson conducted an unannounced visit to the facility for purpose of conducting an updated Fire Clearance inspection, and met with Licensee Liza Valencia, introduced herself and stated the purpose of the visit. The Facility File review was conducted at the Regional Office and additional forms were requested and reviewed on site.

An initial application to operate an Adult Residential Facility (ARF) was received by the Central Applications Bureau (CAB) on 11/15/2021 for a total capacity of six non-ambulatory and one bedridden resident. The previous Fire Clearance was approved on 03/01/2022, for six non-ambulatory and one bedridden resident. The new Fire Clearance was approved on 03/04/2024, for five non-ambulatory and one bedridden resident, but still for a total of six.
Following is a summary of LPA’s observations.

Structure: The Facility is a single-story home located at 725 Golden Bloom Lane, Fallbrook, CA. 92028, and has six resident bedrooms, and three full bathrooms, family room, dining area and kitchen.
Heating/Cooling System: Central heating, and air conditioning system installed with a central panel located in the hallway to control entire house.
Bedrooms: Each bedroom had the required furnishings as required by regulations to include bed, chair, adequate lighting, and an operable smoke alarm/carbon monoxide detector. Required furnishings were observed presently.
Bathrooms: The bathrooms had working toilets, wash basins, and showers. The Administrator informed the LPA the water is tested and logged monthly or as needed, in the residents' bathrooms.
Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Cleaning supplies were secured in a locked cabinet below the sink. Knives/sharp instruments were stored in a locked cabinet. There is adequate room for food storage. LPA Mixson observed the stove to be operational. Refrigerator/freezer were in working condition, CONTINUED.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GOLDEN BLOOM VILLA
FACILITY NUMBER: 374604527
VISIT DATE: 03/22/2024
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and had enough storage for perishable food. There was adequate seating for meals for residents currently at the time of this review. The laundry area with washer and dryer were in a separate room and were clean and free of odors.

Living/Family room: The family room was safe and had adequate seating for residents in care and was neat organized and free of clutter and odors at this time.

Linens and Hygiene Supplies: An adequate supply of linens were stored in the hallway cabinet and a sufficient supply of hygiene and other personal items were seen presently.

Yards/Outside: The entire backyard was secured with a fence, and the outdoor pathways were free of obstructions. There were no bodies of water observed anywhere on the property at this time. and the patio furniture was observed to be assembled and available as needed with a patio covering.
Garage: There was no garage reviewed or observed currently at today’s facility inspection.

Emergency Phone Numbers, and Exit Plan: The required emergency phone numbers, and facility sketch were observed.

General items: Three fire extinguishers were observed and were charged and mounted in kitchen and one was near the front door, the last one was observed in the laundry room. Smoke alarms and carbon monoxide detectors were mounted and had a visible green light and were operable. LPA Mixson observed the required postings posted in a prominent area for review.

The new Fire Clearance: The West wing is now approved as per the new Fire Clearance to meet fire department requirements for future use. Based on today’s health and safety review there were no health and/or safety issues observed or cited per Title 22, Division 6, Regulations.

An exit interview was conducted, and a copy of this report was provided to Liza Valencia, the Administrator.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC809 (FAS) - (06/04)
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