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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202634
Report Date: 07/29/2025
Date Signed: 07/29/2025 01:35:41 PM

Document Has Been Signed on 07/29/2025 01:35 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:BLOSSOM VALLEY CARE HOME 2FACILITY NUMBER:
435202634
ADMINISTRATOR/
DIRECTOR:		UBUNGEN, MAYBELLINEFACILITY TYPE:
740
ADDRESS:23 DECKER WAYTELEPHONE:
(408) 489-9173
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 6CENSUS: 5DATE:
07/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Ronnie and Maybelline UbungenTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct the facility's required - 1 year annual inspection. LPA met with Administrator/Licensee, Ronnie Ubungen and Maybelline Ubungen.

During visit, LPA toured the facility with staff to include the living room, kitchen, resident bedrooms, bathrooms, garage, laundry room, and backyard. All fire exit routes were free and clear of obstruction. LPA observed 2 residents watching TV in the living room and 3 residents in their bedrooms. Facility is retaining 1 resident under hospice care. 3 staff members present are fingerprint cleared and associated to the facility.

Facility temperature maintained at 75 degrees F. Fire extinguisher last serviced on 05/08/2025. Facility has an operable carbon monoxide detector. Facility has at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator temperature maintained at 38 degrees F. Freezer temperature maintained at 0 degrees F. Hot water temperature was measured at 2 out of 2 bathrooms, which measured between 115.7 - 118 degrees F.

Resident bedrooms equipped with proper furniture, linens, and adequate lighting. LPA observed 4 resident beds were equipped with bed rails - 1 resident had full bed rails and 3 residents had half bed rails. The Licensee did not have the physician's order for 4 out of 4 residents. See LIC809-C.
NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: BLOSSOM VALLEY CARE HOME 2
FACILITY NUMBER: 435202634
VISIT DATE: 07/29/2025
NARRATIVE
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LPA observed 1 resident who based on their physician's report is bedridden, but was residing in a room that is not approved for a bedridden resident based on the facility's fire clearance. Licensee will first talk with the family and states a plan to possibly move the resident to the master bedroom which is approved for bedridden resident, to comply with their fire clearance.

LPA reviewed 3 resident files. Based on record review, 2 out of 3 appraisal/needs and services plan (ANS) were updated annually. LPA observed 1 out of 3 resident's reappraisal was not updated annually and the last reappraisal was dated on 08/08/2023. LPA reviewed a total of 5 resident's physician's report and observed 4 out of 5 physician's report was updated within the year. 1 out of 5 resident's who is diagnosed with dementia physician's report was last updated in year 2023. All other required items to include the admission agreement, TB result, consent forms, personal rights, identification/emergency contact information, and safeguard forms were included in the 3 resident files.

LPA reviewed 3 staff files. 3 out of 3 staff has a fingerprint clearance, health screening, TB result, job application and active first aid certification. 2 out of 3 staff members has not completed at least 20 hours of annual training on dementia care.

Facility has an emergency disaster plan. Fire drills are being completed quarterly and the last drill was completed in July 2025. LPA recommended Licensee to also include earthquake drills. Facility has emergency supplies to include extra flashlights, batteries and first aid kit. Facility has an infection control plan. Personal Protective Equipment observed to include gloves, hand sanitizer, gowns and lidded trash bins.

Deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensee/Administrator Ronnie Ubungen and a copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Jackie Jin
NAME OF LICENSING PROGRAM ANALYST: Christine Kabariti
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 07/29/2025 01:35 PM - It Cannot Be Edited


Created By: Christine Kabariti On 07/29/2025 at 12:46 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BLOSSOM VALLEY CARE HOME 2
FACILITY NUMBER: 435202634

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 wherein 2 out of 3 staff members has not completed at least 20 hours of annual training in the topics of this section which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2025
Plan of Correction
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Licensee will submit a statement of the section cited above to LPA Kabariti via email by POC due date of 08/05/2025.
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.
Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:
Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/29/2025 01:35 PM - It Cannot Be Edited


Created By: Christine Kabariti On 07/29/2025 at 12:46 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BLOSSOM VALLEY CARE HOME 2
FACILITY NUMBER: 435202634

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)(3)
Resident Participation in Decisionmaking
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals.

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 wherein 1 resident files reviewed did not have an annual reappraisal and the last reappraisal was dated on 08/08/23 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/05/2025
Plan of Correction
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Licensee will submit a statement of understanding of the section cited above, to LPA Kabariti via email by POC due date, 08/05/2025.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:
Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/29/2025 01:35 PM - It Cannot Be Edited


Created By: Christine Kabariti On 07/29/2025 at 12:50 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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BLOSSOM VALLEY CARE HOME 2
FACILITY NUMBER: 435202634

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87606(c)
(c) To accept or retain a person who is bedridden, other than for a temporary illness or recovery from surgery, a licensee shall obtain and maintain an appropriate fire clearance as specified in Section 87202, Fire Clearance.

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 ensure to comply with their approved fire clearance for a bedridden resident wherein the bedridden resident was not residing in the master bedroom based on their fire clearance, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2025
Plan of Correction
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 Licensee will first talk with the family and states a plan to possibly move the resident to the master bedroom which is approved for bedridden resident, to comply with their fire clearance. Licensee will submit a statement of understanding of the section cited above to LPA Kabariti by 07/30/2025.
Type A
Section Cited
CCR
87608(a)(3)
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

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 wherein the licensee did not obtain a physician's order for 3 residents who utilizes half rails and 1 resident who uses full bed rails which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2025
Plan of Correction
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Licensee will reach out to 4 residents physicians to request for an order for the bed rails. Licensee will submit a statement of understanding of the section cited above to LPA Kabariti by 07/30/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jackie Jin
NAME OF LICENSING PROGRAM MANAGER:
Christine Kabariti
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2025


LIC809 (FAS) - (06/04)
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