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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803611
Report Date: 08/16/2021
Date Signed: 08/16/2021 03:59:35 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:APPLE BLOSSOM GARDENS RESIDENTIAL CARE FACILITYFACILITY NUMBER:
496803611
ADMINISTRATOR:BLANCAFLOR,JOSEPHINEFACILITY TYPE:
740
ADDRESS:476 EILEEN DRTELEPHONE:
(707) 829-8539
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY:6CENSUS: 6DATE:
08/16/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:07 PM
MET WITH:Josephine Blancaflor (Licensee)TIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management- Legal/Non-compliance inspection and met with Licensee, Josephine Blancaflor. This inspection is being completed to ensure compliance with Non-Compliance Conference dated 9/4/2019. LPA conducted a Risk Assessment call with Licensee prior to the visit.

CCR 87468.2 (a)(1) - Additional Personal Rights of Residents in Privately Operated Facilities - To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, phone conversations, and meetings of resident and family groups. LPA/Licensee toured the facility and reviewed current House Rules were the language that states monitors may be use was removed and replaced with the following: "No auditory monitor is placed in any resident's room".

CCR 87465(c)(2) - Incidental Medical and Dental Care - If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication...facility staff designated by the licensee shall be permitted to assist the resident. Medications and medication records were reviewed.

CCR 87705 (f)(1) unsecured tools accessible - The following shall be stored inaccessible to residents with dementia: (1) toxins and other items that could constitute a danger to the resident(s). LPA/Licensee observed dangerous items are stored inaccessible to residents with dementia.

CCR 87465 (h)(2) - Medication accessible - Incidental Medical and Dental Care - Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. Medication was stored inaccessible to other residents.

This case management-legal/non-compliance inspection is complete.
No citations issued during today's inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2021
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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