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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294278
Report Date: 12/08/2023
Date Signed: 12/09/2023 11:40:18 AM


Document Has Been Signed on 12/09/2023 11:40 AM - 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, INC.FACILITY NUMBER:
435294278
ADMINISTRATOR:RONNIE UBUNGENFACILITY TYPE:
740
ADDRESS:4387 SILVERBERRY DRIVETELEPHONE:
(408) 489-9170
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY:6CENSUS: 6DATE:
12/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:RONNIE UBUNGENTIME COMPLETED:
04:36 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with administrator (ADM) Ronnie Ubungen.

LPA observed 6 residents and 3 staff at facility. LPA reviewed 5 resident files and 3 staff files.

Facility license, Administrator Certificate, and personal right posters were observed at main entrance.

LPA toured the facility with ADM inside and out. LPA inspected living room, family room, dinning area, kitchen. There are 2 restrooms, 1 staff live-in room, 3 resident rooms in facility. All the trash cans were observed with covers. Grab bars and non skid floor were observed at the restrooms. Two days perishable foods and seven days non perishable foods were observed sufficient. Room temperature was observed at 71 degree F, hot water temperature was observed at 118 degree F. Temperature of refrigerator was measured at 40 degree F, and temperature of freezer was observed at 0 degree F. Medication cabinet, Knives closet and cleaning products closet were observed locked.

Fire extinguisher was serviced on 4/17/2023. The facility is equipped with fire alarm and carbon monoxide detectors. Smoke detector alarm system was tested, and was working fine. First Aide Box, night lights and emergency flash lights were observed.

Front yard and backyard were inspected. There was no obstruction to block the walkways.

Facility last fire and emergency drill was conducted on 10/20/2023.

No citation was issued today. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this 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: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2023
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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