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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202634
Report Date: 07/10/2024
Date Signed: 07/10/2024 04:48:39 PM


Document Has Been Signed on 07/10/2024 04:48 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: 6DATE:
07/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Ronnie UbungenTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit and met with Administrator (ADM) Ronnie Ubungen.

LPA observed 6 residents and 2 staff in the facility. LPA reviewed 3 resident files and 3 staff files.

LPA toured the facility inside out with ADM. License, Personal Rights posters, and Administrator Certificate were observed in the facility. Living room, dining room, kitchen, 3 shared resident bedrooms, 1 staff room, 2 restrooms, garage, and laundry room were inspected.

Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Room temperature was observed at 72 degree F. Hot water temperature was observed at 116 degree F. Refrigerator temperature was observed at 40 degree F. Freezer temperature was observed at 0 degree F. all the bedrooms were observed with window screens. Bathrooms were observed with nonskid floor.

Fire extinguisher was serviced on 05/21/2024. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Medications closet was observed locked. Knives closet and detergent closet were observed locked.

Flash lights, first aid box and night lights were observed in the facility. Front yard and backyard were inspected. There was no obstruction to block the walkways. The last time the facility conducted the emergency frill is 4/24/2024.

No deficiency noted today. Exit interview was conducted with ADM. The report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024
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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