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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610583
Report Date: 05/13/2025
Date Signed: 05/13/2025 02:02:47 PM

Document Has Been Signed on 05/13/2025 02:02 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:BLOSSOM CARE FOR ELDERLY LLCFACILITY NUMBER:
197610583
ADMINISTRATOR/
DIRECTOR:		NERIA, ROMUELFACILITY TYPE:
740
ADDRESS:1803 W AVE H1TELEPHONE:
(661) 341-7594
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 6CENSUS: 6DATE:
05/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Romuel Neria- AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
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On 5/13/2025 at approximately 10:15 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. LPA was greeted by the caregiver and stated the reason for their visit. Upon LPA’s arrival, LPA observed six (6) residents under the care and supervision of a staff member who has no criminal record clearance nor associated to the facility. The Administrator, Romuel Neria arrived shortly after to assist with today’s visit.

LPA asked for the census, Staff/Resident Roster, and Liability Insurance. LPA conducted a physical plant tour at approximately 12:00 PM and the following was noted:

The facility is a single-story building with four (4) bedrooms and two (2) bathrooms currently occupying six (6) residents. There is no designated staff room. The facility has an approved fire clearance for six (6) non-ambulatory residents of which one (1) may be bedridden. Sign in sheet, hand sanitizer, gloves and masks are available upon entrance.

Common areas: The living rooms and dining rooms were observed to be neat, clean, and organized. The rooms were observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 72°F. LPA observed a fire extinguisher to be located in the kitchen and dated 05/13/2025. LPA observed required postings such as Long-Term Care Ombudsman, Emergency Disaster Plan, and Personal Rights alongside the entrance leading towards the kitchen. A fireplace was observed to be covered and inaccessible to residents. A working telephone was observed.

Kitchen: The kitchen was observed to be clean and free from pests. Sufficient supplies of seven (7) day nonperishable foods and two (2) day perishable foods were observed. Knives/sharps were observed to be kept in a locked kitchen drawer. (continued on LIC 809-C)

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2025
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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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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Document Has Been Signed on 05/13/2025 02:02 PM - It Cannot Be Edited


Created By: Angelica Segovia On 05/13/2025 at 01:24 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLOSSOM CARE FOR ELDERLY LLC
FACILITY NUMBER: 197610583

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 1 working staff member did not have CPR training and was left alone with all six residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2025
Plan of Correction
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The Administrator will email LPA Segovia the CPR training for the working staff member no later than the POC due date. The Administrator will review the regulation being cited and email LPA Segovia an understanding of the regulation no later than the POC due date.
Type A
Section Cited
CCR
87413(a)(1)
Personnel - Operations
(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 1 working staff member did not have any training or required documentation while left supervising all six residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2025
Plan of Correction
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The Administrator will email LPA Segovia the training for the working staff and the Administrator will review the regulation being cited and email LPA Segovia an understanding of the regulation no later than the POC due 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.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Angelica Segovia
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2025 02:02 PM - It Cannot Be Edited


Created By: Angelica Segovia On 05/13/2025 at 01:24 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLOSSOM CARE FOR ELDERLY LLC
FACILITY NUMBER: 197610583

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 1 working staff member did not have criminal record clearance and was left alone to care and supervise all six residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/14/2025
Plan of Correction
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The Administrator will email LPA Segovia the criminal record clearance for the working staff member and that person cannot return to the facility until clearance has been approved. The Administrator will in addition, review the regulation and email LPA Segovia an understanding of the regulation no later than the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Angelica Segovia
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2025 02:02 PM - It Cannot Be Edited


Created By: Angelica Segovia On 05/13/2025 at 01:24 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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLOSSOM CARE FOR ELDERLY LLC
FACILITY NUMBER: 197610583

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in two out of 2 working staff members did not have a Health Screening Report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2025
Plan of Correction
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The Administrator will email LPA Segovia the health screening report for both working staff member no later than the POC due 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.
Troy Agard
NAME OF LICENSING PROGRAM MANAGER:
Angelica Segovia
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2025


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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BLOSSOM CARE FOR ELDERLY LLC
FACILITY NUMBER: 197610583
VISIT DATE: 05/13/2025
NARRATIVE
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The cleaning solutions/toxins were observed to be kept locked underneath the kitchen sink. Kitchen appliances were observed to be working and in proper condition.

Bedrooms: The residents’ rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. Extra linens/covers were observed stored in cabinets located in the hallway’s passageway.

Bathrooms: The bathrooms were checked for cleanliness and proper operation. The hot water temperature was measured within regulations at 120.0 °F.

Laundry Room: The laundry room was observed to be located in the hallway leading towards the bedrooms. LPA observed the laundry room to be kept locked. LPA observed cleaning solutions and toxins stored within the laundry room and inaccessible to residents. The laundry appliances were observed to be working and in proper condition. Garage: The garage can be accessed from inside of the facility and is located next to the laundry room. LPA observed the garage to be used for storage purposes.

Backyard: The backyard of the facility is equipped with a designated shaded area with outdoor furniture for residents. There is no body of water located at the facility.

Medications: The medications were observed stored in a locked cabinets located aside the kitchen. LPA observed staff and resident files to be kept locked in a cabinet located in the staff/reception desk area. First-aid kit observed to be equipped with but not limited to bandages, scissors, digital thermometer, and First Aid Manuel.

Smoke detectors and carbon monoxide observed to be working properly and were tested.

Residents/Staff Records: LPA conducted a complete file review of resident records. Resident records appeared to be complete and updated. Staff records: LPA conducted a complete file review of staff records and observed two (2) working staff file missing required documentation.

There were no other immediate health and safety hazard observed during the day of inspection. Citations issued, please refer to LIC 809-D.

A civil penalty for $100 per day for a maximum of 5 days in the amount of $500 for criminal record clearance violation is being assessed on the attached LIC 421BG.

Exit interview conducted, Appeals Rights given, and a copy of this report was provided to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Troy Agard
NAME OF LICENSING PROGRAM ANALYST: Angelica Segovia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC809 (FAS) - (06/04)
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