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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197610583
Report Date:
06/25/2024
Date Signed:
06/25/2024 10:48:53 AM
Document Has Been Signed on
06/25/2024 10:48 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
N LA & CEN COA AC/SC
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
BLOSSOM CARE FOR ELDERLY LLC
FACILITY NUMBER:
197610583
ADMINISTRATOR/
DIRECTOR:
NERIA, ROMUEL
FACILITY TYPE:
740
ADDRESS:
1803 W AVE H1
TELEPHONE:
(661) 341-7594
CITY:
LANCASTER
STATE:
CA
ZIP CODE:
93534
CAPACITY:
6
CENSUS:
1
DATE:
06/25/2024
TYPE OF VISIT:
Prelicensing
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:
Romuel Neria (Applicant)
TIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Evelin Rios met with Romuel Neria (Applicant/Administrator) for a follow-up Pre-licensing inspection.
LPA needed to verify that the facility has made the corrections needed to meet licensing standards.
LPA conducted a physical plant inspection to
verify grab bar for the toilet in the private bathroom was added correctly and to verify 4 resident bedrooms are fully furnished and furniture is arranged appropriately. Prior to visit Romuel submitted pictures to LPA Rios on 06/16/2024 and 06/17/2024 of corrections made.
Pre-Licensing deficiencies have been resolved. Pre-Licensing is now complete. LPA Rios will notify the Centralized Applications Bureau (CAB) Analyst of the completed Pre-Licensing inspection.
An exit interview was conducted. A copy of this report provided.
SUPERVISORS NAME
:
Eva Miller
LICENSING EVALUATOR NAME
:
Evelin Rios
LICENSING EVALUATOR SIGNATURE
:
DATE:
06/25/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/25/2024
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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