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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435294278
Report Date: 12/23/2025
Date Signed: 12/23/2025 04:51:18 PM

Document Has Been Signed on 12/23/2025 04:51 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, INC.FACILITY NUMBER:
435294278
ADMINISTRATOR/
DIRECTOR:		RONNIE UBUNGENFACILITY TYPE:
740
ADDRESS:4387 SILVERBERRY DRIVETELEPHONE:
(408) 489-9170
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 6DATE:
12/23/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Ronnie UbungenTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced Required 1 Year visit and met with Administrator (ADM) Ronnie Ubungen and Licensee (LIC) Maybelline Ubungen. LPA stated the purpose of the visit.

The facility serves age 60 and over. Five may be non-ambulatory. One may be bedridden. Bedroom #3 and #4 are approved for one bedridden client and hospice waiver for two. LPA observed 6 resident and 3 staff at the time of the inspection.

LPA toured the facility including but not limited to the kitchen, dining, activity room, 3 resident room all shared. 1 staff room, garage, bathroom and exterior perimeter. The exterior perimeter and walkway are free from obstruction/debris. The ramp and back deck are maintained, handrails and ramp is sturdy. LPA observed a gazebo in the backyard. Fence was propped up a bougainvillea plant from the neighbor was hanging over the fence, a frayed window screen was observed from the exterior side by the dining area.

LPA inspected the kitchen and observed food supply for at least 2 days of perishable food and 7 days of non-perishable food. Sharps and medications were locked in secured areas. Cleaning and laundry supplies are in a separate storage and locked. Resident's bedroom have sufficient storage to store personal items. The bathroom is equipped with grab bars and non-skid floors for adults who are non-ambulatory and ambulatory residents. 1 Out of the 2 bathroom is equipped with a toilet seat riser, and bath bench/chair.

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NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2025
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, INC.
FACILITY NUMBER: 435294278
VISIT DATE: 12/23/2025
NARRATIVE
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While inspecting the kitchen drawers LPA observed 4 medications that were not locked and accessible to residents in care. Staff locked the 4 medications expeditiously.

The water temperature in 2 bathrooms when measured with a digital thermometer is at 140.9 to 143.7 degree F. The kitchen water sink measured at 145 degree F. The facility room temperature is at 72 degree F. Refrigerator temperature is at 40 degree F and freezer is at 0 degree F.

The facility is equipped with a fire alarm system that is in good working condition a fire extinguisher inspected on 05/08/2025. Emergency disaster preparedness was done on 08/5/2025. Fire drill was done on 1/18/25, 4/21/25, 7/17/25 and 10/24/25. A first aid kit complete with the guidebook. LPA gave technical assistance for the earthquake drill resources.

LPA Partoza reviewed facility record, 3 staff and 3 residents records such as but not limited to medical assessment (LIC 602A), centrally stored medication and destruction record (CSMDR), appraisal needs and services plan, personal rights, and consent forms. LPA reviewed staff record such as but not limited to training, criminal background clearance, mandated reporting (SOC 341A) and health screening.

Deficiencies were cited during today's visit based on California Code of Regulations (CCR) Title 22 87303 (e)(2) and 87465(h)(2) See LIC 809D. An exit interview was conducted with Administrator (ADM) Ronnie Ubungen and Licensee (LIC) Maybelline Ubungen a copy of the report and appeals rights were provided

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end of report
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/23/2025 04:51 PM - It Cannot Be Edited


Created By: Maria Partoza On 12/23/2025 at 04:12 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, INC.
FACILITY NUMBER: 435294278

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2)Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not maintaining the hot water temperature of not less than 105 deg F and not more than 120 deg F. Water temperature was measured with a digital thermometer at 140 deg F to 145 deg F for 2 bathroom and kitchen, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/24/2025
Plan of Correction
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LIC and ADM stated that they will submit a written plan of correction to monitor the hot water temperature to ensure compliance with the regulation of 105 degree F to 120 degree F. LIC and ADM will submit written plan by the POC due date of 12/24/2025.
Type A
Section Cited
CCR
87465(h)(2)
87465(h)(2) - Incidental Medical and Dental Care (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above by not ensuring medications for 3 residents were kept in a safe locked place that is not accessible to persons other authorized personnel. LPA observed 4 bottles of medication for 3 residents (R1 to R3) that were not locked in a safe secure place, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/24/2025
Plan of Correction
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LIC and ADM stated that they will submit a written plan of correction to ensure that medication are kept in a safe secure place not accessible to persons other than authorized personnel or employees who are responsible for the supervision of the centrally stored medication. LIC and ADM stated the plan will be submitted to LPA by due date of 12/24/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Maria Partoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2025


LIC809 (FAS) - (06/04)
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