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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209300
Report Date: 01/21/2026
Date Signed: 01/27/2026 09:45:29 AM

Document Has Been Signed on 01/27/2026 09:45 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 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: 5DATE:
01/21/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator Rajvinder SamraTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analysts (LPA) B. Miranda conducted an unannounced visit today (January 21, 2026) for the facility’s annual inspection. LPA introduced themselves and was allowed entrance into the facility. LPA met with Administrator Rajvinder Samra.

Facility is licensed for 6 residents and has a current census of 5. Facility has 4 bedrooms and 2.5 bathrooms. One bedroom is for staff, and the other three bedrooms are for residents. Currently 2 bedrooms are shared, and one resident has their own room. Facility Water temperature was checked in the kitchen which read at 111.9 degrees Fahrenheit and in the common bathroom which read at 109.0 degrees Fahrenheit. Fire Extinguisher was serviced February 4, 2025, and has correct charge. Smoke and carbon monoxide detectors were tested and in working order.

There is 1 resident currently on hospice. R1 is currently on oxygen. Facility did not obtain approval from the Dept to retain R1 who has a restricted health condition. The facility did not report to the local fire dept in writing regarding R1 being on oxygen.

Rajvinder Samra Administrator's Certification expires August 9, 2026. Staff files were reviewed. Resident files were reviewed, complete, and current. Physician reports are current and do not indicate residents are at risk for elopement or hygiene products are a danger. Facility provided a log for disaster drills that are conducted quarterly. First aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. There is a locked storage for medications.
NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: Brianna Miranda
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2026
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: BLOSSOM CREEKS ASSISTED LIVING 2 INC.
FACILITY NUMBER: 107209300
VISIT DATE: 01/21/2026
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LPA inspected the exterior and interior of the facility, including the common living spaces, resident bedrooms, bathrooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean, properly furnished, with adequate lighting, and in good repair. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Observed deficiencies were cited during today's inspection per California Code of Regulations, Title 22.

Exit interview was conducted and a copy of this report LIC809, LIC 809D, and appeal rights were provided to Administrator Rajvinder Samra.
NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: Brianna Miranda
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/27/2026 09:45 AM - It Cannot Be Edited


Created By: Brianna Miranda On 01/21/2026 at 01:47 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 CREEKS ASSISTED LIVING 2 INC.
FACILITY NUMBER: 107209300

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(A)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility.

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.R1 is on oxygen and the Licensee did not inform in writing the fire dept. LPA asked Administrator who stated no written statement had been made.
POC Due Date: 01/30/2026
Plan of Correction
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Administrator will write a letter to the local fire dept and a copy will be sent to CCLD by POC date.
Type B
Section Cited
CCR
87618(b)(5)
Oxygen Administration - Gas and Liquid
(5) Ensuring that facility staff have knowledge of, and ability in the operation of the oxygen equipment.

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. Administrator was not able to provide verification of staff training for R1's oxygen equipment.
POC Due Date: 01/30/2026
Plan of Correction
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Administrator will conduct training and provided verificaiton to CCDL by POC date.
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: 01/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2026


LIC809 (FAS) - (06/04)
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