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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294278
Report Date: 01/06/2021
Date Signed: 01/06/2021 04:11:31 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, INC.FACILITY NUMBER:
435294278
ADMINISTRATOR:RONNIE UBUNGENFACILITY TYPE:
740
ADDRESS:4387 SILVERBERRY DRIVETELEPHONE:
(408) 489-9170
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY:6CENSUS: 5DATE:
01/06/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ronnie UbungenTIME COMPLETED:
10:00 AM
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At 9:00AM, Licensing Program Analyst (LPA) Steve Chang and Health Facility Evaluator Nurse Mirabelle Villamin 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.

During today's inspection, facility was virtually toured. Facility has the COVID-19 related signs posted at the main entrance. Facility has the hand sanitizer, wiper, thermometer, sign log with the screening questionnaire at the main entrance. Washing hand signs, hand sanitizer, paper towel were observed at the kitchen and restrooms. Some trash cans without foot pedal were observed. Cloth towel were observed in the restrooms and kitchen. No keeping social distancing signs were posted in the living room. Some beds in the bed rooms do not keep 6 feet apart. PPE supplies, cleaning supplies, and food supplies were checked. The facility has sufficient supplies for PPE, cleaning products and food.

The following are the recommendations:
1. Remove the cloth towel, just use the paper towel.
2. Trash cans should have the foot pedal.
3. Remove some chair in the dinning room, put chairs on the long side of the dinning table.
4. Post the keep the social distancing signs at the common area.
5. Beds should be 6 feet apart or change the orientation of the bed.
6. Post the signs of the sequences of conning and donning PPE.
7. Disinfect the high touch area more often.

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: 01/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2021
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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