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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202634
Report Date: 07/30/2021
Date Signed: 07/30/2021 12:47:13 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
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:
07/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Ronnie UbungenTIME COMPLETED:
01:00 PM
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Licensing Program Analysts (LPAs) Christine Dolores and Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Rose Lustina Caregiver, Ronnie Ubungen, Administrator/Licensee, and Maybelline Ubungen, Administrator.

LPAs toured the facility inside and out to include the entry point in the garage, 2 bedrooms, 2 bathrooms, kitchen, living room and exterior. All fire exit routes were free and clear of obstructions. Gazebo set up in backyard for visitation purposes. Medications are stored in locked closet. Toxins, cleaning supplies, knives and sharp objects are secured.

Facility observed to have designated entry point for COVID 19 symptom screening. Bathrooms observed to be supplied with hygiene products and paper supplies. Hand washing signs were posted in bathrooms. Social distancing signs posted throughout facility. Hand sanitizer available to residents and visitors. LPAs observed supply of Personal Protective Equipment (PPE).

LPAs reviewed the facility policies and procedures to include screening, visitation, isolation, disinfecting, staffing, training, supplies, PPE usage and social distancing.

No citations were issued per the California Code of Regulations, Title 22.

LPAs reviewed report with Ronnie Ubungen and Maybelline Ubungen and a copy provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
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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