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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206795
Report Date: 09/10/2024
Date Signed: 09/10/2024 02:18:51 PM

Document Has Been Signed on 09/10/2024 02:18 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:BLOSSOM CREEKS ASSISTED LIVINGFACILITY NUMBER:
107206795
ADMINISTRATOR/
DIRECTOR:		SAMRA, RAJVINDER KFACILITY TYPE:
740
ADDRESS:501 SOUTH APRICOT AVETELEPHONE:
(559) 598-9515
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY: 6CENSUS: 4DATE:
09/10/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Licensee Rajvinder SamraTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 9/10/2024 Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to continue the annual inspection. LPA introduced herself and was allowed entrance by staff. Licensee Rajvinder Samra was contacted and arrived at the facility shortly after.

LPA reviewed medication for R1, centrally stored log and PRN log did not match for Benzonatate oral pill 100 mg capsule. PRN log total was 21, MARs showed medication was also given in August but was not marked on the PRN log. Amlodine oral pill 5 mg tablet was logged as starting 8/21/24, there was 21 marked as taken, and there are 10 remaining in the bottle, which totals 31 pills, the quantity on the medication is 30. When LPA arrived and reviewed the MARs it did not indicate AM medications were given. Citation issued for Centrally stored medication log and PRN log not being kept maintained.

Licensee explained due to having the facility sprayed for pests non-perishable food was removed and limited food was kept at the facility in order to not contaminate. LPA accepted the explanation for limited food at the facility. Licensee also explained this is the last week at the facility while renovations are taking place. LPA informed Licensee to submit an incident report and verification of building permits. Licensee stated they will be increasing their capacity to 12 after the renovations, LPA informed Licensee there needs to be documents submitted to request the increase. Citation was issued for the pest/insect control issue from the 8/17/2024 visit. Citation was also issued due to emergency exits not opening properly.

LPA reviewed a sample of resident files which are current except for R1's PRN blank prescription form. A sample of staff files was also reviewed which is current and up to date.

Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Licensee Rajvinder Samra.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 09/10/2024 02:18 PM - It Cannot Be Edited


Created By: Brianna Miranda On 09/10/2024 at 01:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BLOSSOM CREEKS ASSISTED LIVING
FACILITY NUMBER: 107206795

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(27)
87555 General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. During the initial visit on 8/17/24 LPA observed cockroaches throughout the facility in the kitchen.
POC Due Date: 09/11/2024
Plan of Correction
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Licensee will have the facility treated for pests.
Type A
Section Cited
CCR
87202(a)
87202 Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA was not able to open exit door from master bedroom or the side door in the garage. These are fire exit routes.
POC Due Date: 09/11/2024
Plan of Correction
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Licensee will have doors fixed to open properly.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Brenda Chan
LICENSING EVALUATOR NAME:Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/10/2024 02:18 PM - It Cannot Be Edited


Created By: Brianna Miranda On 09/10/2024 at 01:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BLOSSOM CREEKS ASSISTED LIVING
FACILITY NUMBER: 107206795

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)(1-4)
87465 Incidental Medical and Dental Care
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.
(1) The specific symptoms which indicate the need for the use of the medication.
(2) The exact dosage.
(3) The minimum number of hours between doses.
(4) The maximum number of doses allowed in each 24-hour period.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA did not observe the prescription blank for R1.
POC Due Date: 09/11/2024
Plan of Correction
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Licensee will get PRN prescription blank for R1's file.
Type A
Section Cited
CCR
87465(a)(6)
87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA reviewed the centrally stored medication log which did not match with the medication count.
POC Due Date: 09/11/2024
Plan of Correction
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Licensee will be switching to the electronic MAR system and be changing to Pharm America. ECP system will be used to keep Centrally Stored Medication Log. Statement will be provide to LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Brenda Chan
LICENSING EVALUATOR NAME:Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024


LIC809 (FAS) - (06/04)
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