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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202634
Report Date: 07/26/2022
Date Signed: 07/26/2022 04:51:03 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/26/2022 04:51 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
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:
07/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Ronnie UbungenTIME COMPLETED:
04:06 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) .Ronnie Ubungen Upon arrival, Staff Julieta Tecson (JT) took LPA body temperature, and checked LPA in the visitor log book.

LPA toured the facility inside out with ADM. COVID posters were observed at entrance and in the facility. Screening station with masks, hand sanitizer, thermometer and visitor log book was observed at the entrance. Living room, kitchen, dinning room and two restrooms were inspected. Trash cans were observed with covers. Paper towels were observed with holders. Posters of washing hands were observed by the sinks in kitchen and restrooms. Cloth towels were observed in the kitchen and restrooms. Three shared resident bedrooms, and laundry area were inspected. One staff live-in room was observed in facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. Room temperature was at 72 degree F, and hot water temperature was at 110 degree F in facility. Five residents and three staff were observed in facility. PPE supplies were observed sufficient.

Fire extinguisher was serviced on 4/20/2022. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors were tested by ADM, and were working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

ADM stated all the residents and staff are fully vaccinated and done with booster. No citation were noted today. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
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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