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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209300
Report Date: 01/21/2025
Date Signed: 01/30/2025 09:55:25 AM

Document Has Been Signed on 01/30/2025 09:55 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
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: 3DATE:
01/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Rajvinder Samra, AdminstratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 1/21/2025, Licensing Program Analyst (LPA) Rachel Bruce arrived unannounced to conduct the Annual inspection. LPA was allowed entrance by Direct Care Staff, Sukhwinder 'Sonia' Kaur. Administrator, Rajvinder Samra (AD) arrived shortly thereafter. LPA explained the purpose of the visit and a tour of the facility, both inside and out was provided by AD.

The facility currently has 3 residents with a capacity of 6. LPA observed required items in bathrooms with hot water measuring 114.5 degrees F. Resident hygiene supplies were properly stored and available. The kitchen was toured and observed in good repair with necessary items and appliances, and sharps/knives were stored in lockable drawer. LPA observed required food supply, including emergency food buckets and paper products. AD has a dedicated cabinet for medications and a lock box for refrigerated medications. Medical dispensing records are computerized and meet regulation.
LPA reviewed both staff and resident files. No issues noted, all required documentation was present and in compliance.

Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility including outdoors. First aid kit located in kitchen cabinet and found to contain required items.
Two fire extinguishers located in facility (hallway and kitchen) and were serviced in February 2024 by Valley Fire. Smoke and Carbon Monoxide detectors were tested and found to be operational. Administrator’s certification current and confirmed to be in active status.

A copy of this report and exit interview conducted with AD.

A copy of this document will be sent via email to administrator.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Rachel A Bruce
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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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