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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209300
Report Date: 01/19/2023
Date Signed: 01/19/2023 10:23:17 AM

Document Has Been Signed on 01/19/2023 10:23 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 CREEK ASSISTED LIVING 2FACILITY NUMBER:
107209300
ADMINISTRATOR:SAMRA, RAJVINDERFACILITY TYPE:
740
ADDRESS:2770 NORTH BURGAN AVENUETELEPHONE:
(559) 598-9515
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY: 6CENSUS: 0DATE:
01/19/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:32 AM
MET WITH:Licensee Rajvinder SamraTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) K.Kaur conducted a Pre-licensing Inspection on this date. LPA met with Licensee Rajvinder Samra. A tour of the facility was conducted together.

This is new facility with no residents in placement. The facility was observed to be at a comfortable temperature, clean, in good repair. No passageway obstructions or fire hazards were observed inside or
outside. Common areas were properly furnished and well-lit throughout. The dining room is equipped with a
table and chairs, living room is equipped with adequate sofas and recliners for residents, adequate outside
space for rest and recreational.

Perishable and non-perishable food supply appeared adequate. Knives will be locked in the kitchen cabinet.
Cleaning and Chemical supplies are kept in locked in the laundry room. Residents' bedrooms were observed to be adequately furnished with bed, dresser, and adequate lighting. Mattresses and linen were in good condition. Extra linen and towels are available. Hot water temperature measured at 114.5 degrees F. Carbon monoxide and smoke alarm detectors installed and operational. Grab bars installed in showers and by toilets, non-skid mats in place, hand soap and paper towels available for use. Trash cans with tight fitting lids are in place. Fire extinguisher was serviced on 12/5/2022 and fully charged. Medications and first aid kit are locked in the kitchen cabinet. Complaint poster posted, resident council info posted, residents' rights posted, emergency disaster plan posted. Gate is self-closing and self-latching.

Component III was also conducted and completed. Exit interview was conducted. Pre-licensing requirements
were met. An exit interview was conducted with Licensee. Report signed on-site by Licensee and printed copy provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2023
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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