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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209457
Report Date: 08/01/2024
Date Signed: 08/01/2024 11:25:40 AM

Document Has Been Signed on 08/01/2024 11:25 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:BLOSSOM CREEKS ASSISTED LIVING 3 INC.FACILITY NUMBER:
107209457
ADMINISTRATOR/
DIRECTOR:
SAMRA, KAUR RAJVINDERFACILITY TYPE:
740
ADDRESS:6406 EAST HEATON AVETELEPHONE:
(559) 598-9515
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY: 6CENSUS: 0DATE:
08/01/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Rajvinder SamraTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analysts (LPAs) Katie Brown and Daiquiri Boyd arrived at the facility to conduct a Pre-Licensing Inspection. LPA met with Administrator (AD) Rajvinder Samra

LPAs began the tour by entering through the front door of the 4 bedroom - 2 bathroom – one story home. All required postings were hung. Common areas were found to be well lit with ceiling fans throughout. Furniture was observed to be properly spaced and in good condition. Flooring is intact throughout the home. Smoke and Carbon Monoxide detectors were tested and found to be I working order. The Fire Extinguisher was serviced 3/15/2024 by Valley Fire. LPA observed additional supply of paper products, bed linens, towels, personal hygiene/grooming products. Resident rooms are found to be in good repair and contained required linens, furnishings, and lighting. Bedrooms have ceiling fans which were working. The resident bathrooms are clean, in good repair with grab bars and faucets delivering hot water at 115 degrees.

The kitchen was observed to have a supply of dishes, plates, utensils and cooking items. Food storage areas are clear and appropriate for food preparation. Cleaning supplies, chemicals, and sharps/knives are all locked as required. Appliances were found to be in working order. LPA observed the required food supply. Resident medications will be stored in a designated locking hall cabinet. The First aid kit contains all the required items. Doors and passageways are unobstructed throughout the inside of the home.

Outside of the facility was toured. There is a covered seating area and a self-releasing gate found to be working properly. There is a storage shed in the backyard. AD unlocked the shed and LPA observed inside. LPA called and confirmed the facility phone number by calling (559) 554-3094.

See Lic809C for continuation of this report
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: BLOSSOM CREEKS ASSISTED LIVING 3 INC.
FACILITY NUMBER: 107209457
VISIT DATE: 08/01/2024
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Emergency Disaster and Infection Control Plans were reviewed and COMP III was conducted during this visit with AD. The applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.

An exit interview was conducted and a copy of this report was left with AD, whose signature confirms receipt of these documents.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC809 (FAS) - (06/04)
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