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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202634
Report Date: 01/04/2021
Date Signed: 01/04/2021 04:33:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:BLOSSOM VALLEY CARE HOME 2FACILITY NUMBER:
435202634
ADMINISTRATOR:UBUNGEN, MAYBELLINEFACILITY TYPE:
740
ADDRESS:23 DECKER WAYTELEPHONE:
(408) 489-9173
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:6CENSUS: 5DATE:
01/04/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Ronnie UbungenTIME COMPLETED:
11:30 AM
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At 10:30AM, Licensing Program Analyst Steve Chang and Program Clinical Consultant Roxane Fangon conducted a tele visit with PCC via zoom platform. Due to COVID-19 preventive measures, facility visits have been suspended. LPA met with administrator (ADM) Ronnie Ubungen. ADM stated the facility has COVID test. ADM will let LPA know today's test result. During today's inspection, facility was virtually toured. Facility has the COVID-19 related sign posted at the main entrance, and by the garage door. The facility uses the garage as entrance and exit. Facility has hand sanitizer, thermometer, sign in log at the garage. COVID-19 signs were posted at the hallway, the common area, and restrooms. Washing hand signs, hand sanitizer, paper towel, and trash can with lid were observed at the restrooms. Administrator demonstrated conning and donning PPE. Paper towel, hand sanitizer, trash can with lid were observed in the kitchen. PPE supplies, cleaning product supplies, and food supplies were checked.

The following are the recommendations:
1. Paper towel should be with the holder.
2. Remove some of the chairs for the dinning room.
3. Have the screening questionnaire printed out to screen the visitor.
4. Keep the log for temperature and symptoms for residents and staff.
5. The staff should wear N95, should not wear KN95.
6. Please read the information sent through the other email.
7. Check more often for residents and staff temperature.

No deficiencies cited during today's tele visit. A copy of this report emailed to the facility for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2021
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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