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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208882
Report Date: 12/15/2021
Date Signed: 12/16/2021 09:42:54 AM

Document Has Been Signed on 12/16/2021 09:42 AM - 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:BLOSSOM HAVEN, INC.FACILITY NUMBER:
107208882
ADMINISTRATOR:LY-YANG, XIAMYFACILITY TYPE:
740
ADDRESS:6618 E HARWOOD AVETELEPHONE:
(559) 458-1958
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY: 6CENSUS: 4DATE:
12/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:54 AM
MET WITH:Administrator Xiamy Ly-YangTIME COMPLETED:
01:45 PM
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On 12/15/2021, Licensing Program Analysts (LPAs) K. Kaur and A. Walton arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPAs introduced themselves, stated the purpose of the visit, and were granted entry to the facility by Caregiver. Caregiver contacted Administrator Xiamy Ly-Yang, who arrived shortly thereafter.

Visitor log-in/temperature check, masks, and disinfection station were observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Hand washing and other various Covid-19 related signs were observed in the common areas.

Facility tour conducted with Administrator. All pathways, entrances and exits were clear from obstructions. No fire clearance issues. Facility staff observed with facial coverings. LPAs toured 4 private bedrooms with adequate furnishings. LPAs toured the facility kitchen. LPAs observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. LPAs observed a 30-day supply of PPE and cleaning supplies. LPAs checked residents' medication and observed a 30-day supply. Staff files were reviewed for good health and COVID Training. LPA did not observe updated emergency contact information for Resident’s.

No deficiencies were observed.

LPAs are requesting the following documents be submitted to the Fresno CCL office by 12/27/2021: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Licensee. As a COVID-19 precautionary measure, a copy of this report will be provided via email. Report signed on-site by Facility Representative.
SUPERVISORS NAME: Brenda White
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2021
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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