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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604890
Report Date: 06/26/2026
Date Signed: 06/26/2026 05:03:22 PM

Document Has Been Signed on 06/26/2026 05:03 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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:BLOSSOM VALLEY RESIDENTIAL CAREFACILITY NUMBER:
374604890
ADMINISTRATOR/
DIRECTOR:		PATRICIA PENAFACILITY TYPE:
740
ADDRESS:10044 BLOSSOM VALLEY RDTELEPHONE:
(619) 857-5558
CITY:EL CAJONSTATE: CAZIP CODE:
92021
CAPACITY: 6CENSUS: 4DATE:
06/26/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Administrator Trish Pena and Caregiver Leandra SmithTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced visit to conduct a required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves and discussed the purpose of the visit with Administrator Trish Pena. LPA began the annual inspection with Trish and completed the inspection with Care Staff Leandra Smith.

During today’s inspection, there were a total of 4 residents in care. According to the facility's license, the facility is approved for six residents, age 60 and over. Rooms #1 and #2 are for ambulatory residents and Room #3 can have two non-ambulatory residents. Hospice is approved for two (2).This facility does not feature a secured perimeter or delayed egress doors.


LPA, accompanied by Leandra, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment.

The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was 71 degrees F. Hot water temperature at taps accessible to residents were compliant.

No pools or bodies of water were observed on the premises. Per Leandra Smith, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. (CONTINUED ON NEXT PAGE, LIC 809C)

NAME OF LICENSING PROGRAM MANAGER: Robyn Clark
NAME OF LICENSING PROGRAM ANALYST: Liliana Silveira
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BLOSSOM VALLEY RESIDENTIAL CARE
FACILITY NUMBER: 374604890
VISIT DATE: 06/26/2026
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(CONTINUED FROM PAGE 1, LIC 809)

First aid kit(s) were complete and readily accessible. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. Required licensing postings were observed in visible areas of the facility.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored in the kitchen. Cooking/dining equipment and utensils were present. There are activities for the residents to participate in.

LPA interviewed staff and residents. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. Confidential records were stored in locked areas.

The facility is approved for two (2) non-ambulatory residents in bedroom #3. Based on a review of resident medical evaluations, there are currently three (3) non-ambulatory residents living in the home.

An immediate civil penalty in the amount of $500 is being assessed on an LIC 421IM for a fire clearance violation in accordance with Section 1568.0822 (2)(A) of the Health and Safety Code.

An exit interview was conducted with Leandra, and copies of this report, LIC 421IM, and Licensee/Appeal Rights (LIC 9058 03/22) were provided via email. The signature below serves as acknowledgment of receipt of the documents.

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NAME OF LICENSING PROGRAM MANAGER: Robyn Clark
NAME OF LICENSING PROGRAM ANALYST: Liliana Silveira
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/26/2026 05:03 PM - It Cannot Be Edited


Created By: Liliana Silveira On 06/26/2026 at 02:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BLOSSOM VALLEY RESIDENTIAL CARE
FACILITY NUMBER: 374604890

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/27/2026
Section Cited
CCR
87204(b)

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(b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents.
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Licensees will submit an LIC 200 Application for a fire clearance within 24 hours to change their clearance from 2 non-ambulatory to 4 non-ambulatory. If Licensee is not approved for the fire clearance, Licensee will serve the client with an eviction notice.
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This requirement is not met as evidenced by:
Based on a review or resident medical assessments, the licensee did not comply with the section cited above in 1 out of 4 clients, which poses an immediate health risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Robyn Clark
NAME OF LICENSING PROGRAM MANAGER:
Liliana Silveira
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2026


LIC809 (FAS) - (06/04)
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