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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002617
Report Date: 06/02/2021
Date Signed: 06/04/2021 10:36:58 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:CHERRY BLOSSOM ASSISTED LIVINGFACILITY NUMBER:
515002617
ADMINISTRATOR:KNOLL, LORIFACILITY TYPE:
740
ADDRESS:1880 LIVE OAK BLVDTELEPHONE:
(530) 212-8010
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY:79CENSUS: 33DATE:
06/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lori Knoll TIME COMPLETED:
12:23 PM
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Licensing Program Analyst (LPA) Hiratsuka arrived at the facility unannounced on 06/02/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Administrator Lori Knoll, Activities Director Sam Clark, and Care Coordinator Michelle Hernandez, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted Care Coordinator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. Additionally, LPA were screened by facility staff upon entering the facility.

This facility has a fire clearance for 79 residents of which 15 may be bedridden. This facility has two buildings. The smaller building has 11 resident rooms that may be shared, a small laundry room, a small sitting room for the residents, and a room that has a refrigerator, microwave, and sitting area for residents. The rooms either have a private half-bathroom or some are set up where two rooms share a half-bathroom.
The main building currently has 27 resident rooms, main common area, dining area, kitchen, offices, a laundry room, and medication room.. There is one resident room that is currently being used as a staff room that will make it 28 resident rooms if it is to be use for residents.. The rooms either have a private half-bathroom or some are set up where two rooms share a half-bathroom. There are two common shower rooms. Outside was inspected. There are two enclosed areas and one leads to the second building. .

Multiple topics were discussed during this visit including infection control.

No deficiencies cited.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021
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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