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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701308
Report Date: 01/18/2025
Date Signed: 01/18/2025 11:55:16 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/18/2025 11:55 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BLOSSOMKAREFACILITY NUMBER:
392701308
ADMINISTRATOR/
DIRECTOR:		GILBERT, LAQUETAFACILITY TYPE:
740
ADDRESS:2101 S. B STREETTELEPHONE:
(888) 725-5662
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 3CENSUS: 0DATE:
01/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Laqueta Gilbert TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 1/18/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA met with Licensee, Laqueta Gilbert and explained the purpose of the visit. The purpose of this visit was to conduct an annual visit.

Current census was 0. A brief interview with Licensee Gilbert was conducted.
This facility is intended to hold 3 older adults of which all may be non-ambulatory with a hospice waiver for 2. The administrator has a current administrator certificate #6068206740 and expires on 12/25/2025.
A tour of the facility was conducted.
Smoke detectors and carbon monoxide detectors were observed to be in good compliance at this time. Fire extinguisher was serviced by a local fire company C.R. Fire Inc on 11/15/2024.
Dining area, living area, and all other areas intended for resident use were toured and observed to be furnished and maintained in compliance at this time.
Kitchen area was toured. Cabinets and drawers were opened and reviewed by this LPA along with the Applicant. Food supply for 2-day perishable and 7-day nonperishable quantities were reviewed to make sure that this facility was in compliance at this time.
Medication cabinet, located in the kitchen area, was toured. First aid kit was observed to be present and contained all required components at this time.
A tour of the resident bedrooms was conducted. Furnishings and furniture intended for use by the clients were observed to be sufficient and able to meet the needs of the clients at this time. A tour of the resident bathrooms was conducted. Hot water temperatures were taken and measured within the allowed range of 105-120 degrees. Linen closet was observed to contain a sufficient supply of towels and linens able to meet the needs of the residents at this time. A tour of the exterior grounds was conducted.
A review of the facility perimeter fence, side gates, and walkways were observed to be maintained in compliance at this time with no hazards present.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BLOSSOMKARE
FACILITY NUMBER: 392701308
VISIT DATE: 01/18/2025
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Garage area was toured. A washer and dryer was identified.. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.

The following forms and documents were requested to be updated and submitted into CCL.
-LIC 308
-LIC 400
-LIC 500
-LIC 610e

No deficiencies were observed or cited during this annual visit. A copy of this report was given to Facility Designated Administrator.

Exit interview.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2025
LIC809 (FAS) - (06/04)
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