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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604527
Report Date: 06/25/2024
Date Signed: 06/25/2024 04:28:07 PM


Document Has Been Signed on 06/25/2024 04:28 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 ASC, 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: 5DATE:
06/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Liza Valencia, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Jacqueline Shaw Ross arrived at the facility unannounced to conduct an annual inspection. LPA was greeted by Liza Valencia, Administrator and the purpose of the visit was explained. Present at the facility were one (1) staff member and five (5) clients. LPA conducted staff interviews, however all clients declined to be interviewed due their mental and physical conditions. The facility is a one story seven (7) bedroom, three (3) bathroom home. All bedrooms are private. The home is approved for five (5) non-ambulatory clients and one (1) bedridden client for a total of six (6) clients. A tour of the facility was conducted inside and out. The smoke alarm system was tested and found operable. Hot water temperature was tested at 110 degrees Fahrenheit. Food was stored in a safe and healthful manner. The facility had a 2 day supply of perishable food items and 7 day supply of nonperishable food items.

LPA reviewed staff and client records. Review of staff records indicate all staff have criminal record clearances and are appropriately associated to the facility. Staff files had the required documentation including First Aid Certifications and training documents that included recent training. Review of the facility training binder showed the following refresher training completed include: Alzheimer's, Emergency Disaster, Postural Supports, Restricted Conditions, Hospice, Reporting Abuse, Food Handling, Dementia, Fall Prevention and Medication training. Review of client files revealed all client records are current and up to date. LPA inspected medications and medications appear to be dispensed appropriately according to physician's orders. The outdoor space is free of hazard and has shaded areas with plenty of seating. Emergency drills are conducted quarterly. Fire extinguishers are fully charged. No weapons, guns or ammunition are stored at the facility.

During the inspection, no deficiencies were observed. An exit interview was conducted and a copy of the report and LIC 811 was provided to Liza Valencia, Administrator.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw RossTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2024
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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