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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294278
Report Date: 12/27/2022
Date Signed: 12/27/2022 04:55:23 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/27/2022 04:55 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, 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: 4DATE:
12/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:RONNIE UBUNGENTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with administrator (ADM) RONNIE UBUNGEN.

Upon Arrival, ADM took LPA's body temperature, and checked LPA in the visitor log book. LPA observed the COVID posters in the facility. Two staff and four residents were observed in facility.

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. Cloth towels were observed in kitchen and in restrooms. There were posters of washing hands for 20 seconds by the sinks in kitchen and restrooms. Two days perishable foods and seven days non perishable foods were observed sufficient. Room temperature was observed at 74 degree F, hot water temperature was observed at 113 degree F. Medication cabinet, Knife closet were observed locked. Cleaning products closet was observed locked. PPE supplies were observed sufficient. Fire extinguisher was serviced on 6/10/2022. The facility was equipped with smoke and carbon monoxide detectors. Smoke detector alarm system was tested, and was working fine. Front yard and backyard were inspected. There was no obstruction to block the walkways.

ADM stated all the residents and staff are fully vaccinated and done with booster shots. ADM already submitted the Infection Control Plan to LPA.

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: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2022
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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