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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294278
Report Date: 12/06/2024
Date Signed: 12/06/2024 05:15:57 PM

Document Has Been Signed on 12/06/2024 05:15 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:BLOSSOM VALLEY CARE HOME, INC.FACILITY NUMBER:
435294278
ADMINISTRATOR/
DIRECTOR:		RONNIE UBUNGENFACILITY TYPE:
740
ADDRESS:4387 SILVERBERRY DRIVETELEPHONE:
(408) 489-9170
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
12/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:06 PM
MET WITH:RONNIE UBUNGENTIME VISIT/
INSPECTION COMPLETED:
04:29 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with administrator (ADM) Ronnie Ubungen.

LPA observed 5 residents and 2 staff at facility. LPA reviewed 3 resident files and 3 staff files. 2 Out of 3 resident files were observed that centrally stored medication forms were not matched with their medications.

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. Grab bars and non slipping resisted floor were observed at the restrooms. Two days perishable foods and seven days non perishable foods were observed sufficient. Room temperature was observed at 68 degree F, hot water temperature was observed at 119 degree F. Temperature of refrigerator was measured at 45 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 5/21/2024. 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 10/20/2024.

Citation was issued today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was provided to ADM.
Romeo ManzanoTELEPHONE: (408) 277-1289
Chihhsien ChangTELEPHONE: (408) 904-9843
DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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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Document Has Been Signed on 12/06/2024 05:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: BLOSSOM VALLEY CARE HOME, INC.
FACILITY NUMBER: 435294278

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that 2 Out of 3 resident files were observed not matched with their medications which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2024
Plan of Correction
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Administrator stated to submit a plan of correction by the POC due date to ensure residents' centrally stored medication forms were well maintained, and to provide staff training for medications. Administrator agreed to submit the training log to CCL office.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo ManzanoTELEPHONE: (408) 277-1289
Chihhsien ChangTELEPHONE: (408) 904-9843

DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024

LIC809 (FAS) - (06/04)
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