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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208882
Report Date: 12/16/2025
Date Signed: 12/16/2025 11:09:03 AM

Document Has Been Signed on 12/16/2025 11:09 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:BLOSSOM HAVEN, INC.FACILITY NUMBER:
107208882
ADMINISTRATOR/
DIRECTOR:		JALAO, LY SYFACILITY TYPE:
740
ADDRESS:6618 E HARWOOD AVETELEPHONE:
(559) 515-6615
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY: 6CENSUS: 4DATE:
12/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:14 AM
MET WITH:Administrator Ly Sy JalaoTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
NARRATIVE
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On 12/16/2025 Licensing Program Analysts (LPAs) B. Miranda and J. Duarte arrived at the facility unannounced to conduct an annual inspection. LPAs were greeted by staff Ahli Vang and allowed entrance into the facility. Administrator Ly was contacted and arrived shortly after.

Facility is licensed for a capacity of 6 and has a current census of 4. Upon arrival LPA observed residents siting in the living room waiting to go to day program. Fire extinguisher was last serviced 12/18/2025 and still holds charge. Smoke detectors & carbon monoxide detectors were tested and are in working order. LPAs observed knives and medication to be locked and inaccessible to residents in care. LPAs observed resident rooms which are properly furnished with adequate lighting. Exits are accessible and free from obstruction.

During the tour LPA observed the dishware in the kitchen needing to be cleaned due to buildup at the bottom of the dishware. LPA observed tools accessible to residents in the garage and outside in the cabinets/drawers. LPA observed an outside cooking area needing to be cleaned to prevent pests. Administrator verified there is no current infection control plan in place or completed. LPAs tested water in different areas which did not meet the requirement of 105 degrees.

LPAs reviewed resident files which are current and up to date. A sample of staff files were reviewed and are current and up to date.

Exit interview was conducted. A copy of this report LIC809, LIC809D, and appeal rights were provided to Administrator Ly Sy Jalao.
NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: Brianna Miranda
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 12/16/2025 11:09 AM - It Cannot Be Edited


Created By: Brianna Miranda On 12/16/2025 at 10:20 AM
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: 12/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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. LPA observed the water in the hall bathroom to read at 68.5 degrees Farhenhiet, master bathroom sink 96.4, and master shower to read at 79.8.
POC Due Date: 12/17/2025
Plan of Correction
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Licensee will have maintance make adjustments to water heater. Pictures to verify will be sent to LPA by POC due date.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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. LPA observed cleaning supllies, pruning sheers, and small sheers outside in an unlocked drawer/cabinet. LPA observed tools in the garage which are accessible to residents.
POC Due Date: 12/17/2025
Plan of Correction
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Licensee will provide LPA with pictures by POC due date. Pictures will shows tools and cleaning supllies have been romved and locked.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Brianna Miranda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/16/2025 11:09 AM - It Cannot Be Edited


Created By: Brianna Miranda On 12/16/2025 at 10:20 AM
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: 12/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

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/posed a potential health, safety or personal rights risk to persons in care. Licnesee does not have an infection control plan completed.
POC Due Date: 12/31/2025
Plan of Correction
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Licnesee will complete an infection control plan and provide to plan to LPA by POC due date.
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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/posed a potential health, safety or personal rights risk to persons in care. LPA observed buildup in dishwasher, outside area used for cooking at times needs to be cleaned to prevent actracting pests, Outside refridgerator and freezer needs to be cleaned due to spillage.
POC Due Date: 12/31/2025
Plan of Correction
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Licensee will have the items listed aboved cleaned and pictures will be sent to LPA by POC due date. Licensee will follow-up with staff regarding cleaning.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Brianna Miranda
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2025


LIC809 (FAS) - (06/04)
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