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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803611
Report Date: 02/12/2024
Date Signed: 02/12/2024 12:23:23 PM


Document Has Been Signed on 02/12/2024 12:23 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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:
02/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Jojo Blancaflor (Licensee)TIME COMPLETED:
12:38 PM
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Licensing Program Analyst (LPA), Cuadra arrived unannounced to conduct an Annual Required Inspection and met with Licensee Jojo Blancaflor. Required postings were observed. Annual fees are current.

LPA/Licensee initiated a tour of the facility at 9:00 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in resident's bathroom measured at 119.3, 105.6 and 106.7 degrees F which are within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked. Fire extinguisher was last inspected July, 2023. Smoke detectors and Carbon Monoxide detector located throughout the facility were tested and operational. Exit doors have auditory alert system and were functional at time of visit. Last disaster drill conducted on 1/5/24.

File review was initiated at 9:30am. Four staff files and six resident files were reviewed. Staff have required First Aid and CPR certificates, training records were reviewed. All resident's files have current medical assessments and care plans. Administrator Certificate for Licensee Josephine Blancaflor, 6015304740 expires 7/14/24. Medications and medication records were reviewed.

Licensee submitted updates of the following documents: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Liability insurance, control of property and Emergency Disaster Plan (LIC610E) if there are any changes.

No deficiencies during today's visit. Exit interview conducted with Licensee and a copy of this report was given.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024
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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