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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803611
Report Date: 02/20/2025
Date Signed: 02/20/2025 12:44:50 PM

Document Has Been Signed on 02/20/2025 12:44 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:APPLE BLOSSOM GARDENS RESIDENTIAL CARE FACILITYFACILITY NUMBER:
496803611
ADMINISTRATOR/
DIRECTOR:
BLANCAFLOR,JOSEPHINEFACILITY TYPE:
740
ADDRESS:476 EILEEN DRTELEPHONE:
(707) 829-8539
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY: 6CENSUS: 5DATE:
02/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Licensee, Josephine BlancaflorTIME VISIT/
INSPECTION COMPLETED:
12:55 PM
NARRATIVE
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Licensing Program Analyst (LPAs), Deniz and Cuadra arrived unannounced to conduct an Annual Required Inspection and met with Licensee/Administrator Josephine Blancaflor. Required postings were observed. Annual fees are paid during our visit.

LPAs/Licensee initiated a tour of the facility at 9:20 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Water temperature in resident's bathroom measured at 119.3, 121.4, and 121.8 degrees F which are not within allowable range of 105 to 120 degrees F (Deficiency cited). Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Cabinets containing cleaning supplies and other items that could pose a risk were locked.Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked. Fire extinguisher was last inspected May, 2024. Smoke detectors and Carbon Monoxide detector located throughout the facility were tested and operational. Exit doors have auditory alert system and were functional at time of visit. Last disaster drill conducted on 1/27/25. File review was initiated at 10:00am. Three staff files and five resident files were reviewed. Staff have required First Aid and CPR certificates, training records were reviewed. All resident's files have current medical assessments and care plans. Administrator Certificate for Licensee Josephine Blancaflor, 6015304740 expires 7/14/26. A spot of medications revealed some discrepancies as follow; there was an unrecorded medication Hydrocodone -Acetaminophen 10-325 MG in the medication log for resident (R1) and Tab-A-Vite Tabs Major medication for resident (R2) had a missing information in the centrally stored medication log (Deficiency cited).

Licensee submitted updates of the following documents: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Liability insurance and control of property.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Licensee and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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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Document Has Been Signed on 02/20/2025 12:44 PM - It Cannot Be Edited


Created By: Ali Deniz On 02/20/2025 at 12:28 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: APPLE BLOSSOM GARDENS RESIDENTIAL CARE FACILITY

FACILITY NUMBER: 496803611

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
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 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the hot water being checked at 134.9 degrees Fahrenheit, which is not in compliance with regulation, the licensee did not comply with the section cited above which poses an immediate health, safety risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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Licensee/Administrator to ensure the hot water is monitored and under 120.degrees Fahrenheit, and not to be under 105. degrees Fahrenheit. Monitor the hot water for a period of one week (7 days). Submit a copy of the hot water log, and a plan on how the facility will ensure the hot water is maintained in compliance with regulation. Submit plan of correction and follow up with copy of hot water log and maintenance plan by 2/28/25.
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication review, centrally stored medication log was not accurate in 2 of 5 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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Licensee to submit self certification that medication training will be conducted for all staff that administer medications by POC due date of 02/28/2025. Training to include the following: Trainer, Date of Training, Topics, Job Role, Staff Names and Signatures. Proof of Training to be submitted to CCL by POC due date of 02/28/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Ali Deniz
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
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