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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208882
Report Date: 12/06/2022
Date Signed: 12/06/2022 01:58:05 PM

Document Has Been Signed on 12/06/2022 01:58 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 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:
12/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator Xiamy Ly-YangTIME COMPLETED:
02:15 PM
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On 12/06/2022, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPA introduced self, stated the purpose of the visit, and was 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.

All pathways, entrances and exits were clear from obstructions. Facility staff observed with facial coverings. LPA toured 4 bedrooms with adequate furnishings. LPA toured the facility kitchen. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. At 1:20 PM LPA observed the Fire extinguisher to be expired with a service date of 6/30/2021. LPA checked residents' medication and observed a 30-day supply. Staff files were reviewed for good health and COVID Training. LPA observed updated emergency contact information for Resident’s.

Deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22,
Division 6.

LPA is requesting the following documents be submitted to the Fresno CCL office by 12/13/2022: 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 Administrator. Report signed on-site; a copy of this report will be provided via email.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
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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Document Has Been Signed on 12/06/2022 01:58 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 12/06/2022 at 01:27 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 HAVEN, INC.
FACILITY NUMBER: 107208882

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203

87203
FIRE SAFETY: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the
protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1. Fire extinguisher was expired
with a service date of 6/30/2021, which poses an immediate health, safety or personal rights risk to persons in care..
POC Due Date: 12/07/2022
Plan of Correction
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Licensee to either have fire extinguisher serviced or buy new and submit pictures as proof of POC.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:See Moua
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022


LIC809 (FAS) - (06/04)
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