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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209300
Report Date: 10/16/2024
Date Signed: 10/16/2024 12:21:21 PM

Document Has Been Signed on 10/16/2024 12:21 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:BLOSSOM CREEKS ASSISTED LIVING 2 INC.FACILITY NUMBER:
107209300
ADMINISTRATOR/
DIRECTOR:
SAMRA, RAJVINDERFACILITY TYPE:
740
ADDRESS:2770 NORTH BURGAN AVENUETELEPHONE:
(559) 598-9515
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY: 6CENSUS: 4DATE:
10/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Rajvinder Samra, Administrator TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 10/26/2024, Licensing Program Analyst (LPA) R Bruce, arrived at the facility for an unannounced case management and met with Rajvinder Samra, Administrator. The purpose of the visit was to discuss recent incident reports and when it is appropriate to send a report.

Discussion was held regarding a recent resident (no longer at the house) who would call emergency services on a consistent basis when not necessary. LPA explained the necessity of reporting anytime law enforcement is at the house, also it is necessary to report any change in medical condition, anytime they go to the hospital, any change in level of care etc.

Administrator will speak with staff on how and when to report and continue to review the reports before submitting. No deficiencies issued at today's visit.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Rachel A Bruce
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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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