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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803611
Report Date: 02/12/2026
Date Signed: 02/12/2026 12:47:55 PM

Document Has Been Signed on 02/12/2026 12:47 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
CCLD Regional Office, 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:
02/12/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:47 AM
MET WITH:Josephine Blancaflor (Licensee)TIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA), Cuadra arrived unannounced to conduct an Annual Required Inspection and met with Licensee Josephine Blancaflor. Required postings were observed. Annual fees current. There is one resident receiving hospice services.

LPA/staff toured the facility at 9:00 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 105.3, 115.7 and 116.2 degrees F which are within regulations. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Residents were observed participating in activities in common areas. 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, 2025. 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 12/13/25.

At approximately 9:15am LPA/staff observed that washcloths were hanging on the bathroom towel bars for resident use in two out of three resident bathrooms that are shared by residents. LPA/staff observed that the bathrooms didn’t have paper towels for resident use to help ensure sanitary hygiene care for all residents. Licensee put paper towels in the bathrooms and LPA explained that regulation states that the use of common wash cloths and towels shall be prohibited.

File review was initiated at 9:30am. Three staff files and five resident files were reviewed. Staff have required First Aid and CPR certificates, training records were reviewed. Continue on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2026
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: APPLE BLOSSOM GARDENS RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 496803611
VISIT DATE: 02/12/2026
NARRATIVE
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Continued from LIC809...
Residents receiving hospice services had a care plan that appears to be accurate to services being provided. Residents' care plans seems to have a person-centered approach and they are updated. Medical assessments are current and included a description of any known behavioral expression. Administrator Certificate for Licensee Josephine Blancaflor, 6015304740 expires 7/14/26. Medication & records reviewed.

At approximately 10:00am, based on records review, resident's (R1) physician report (LIC602) dated 10/17/25 indicates that R1 has a history of pressure injury right heel. Although R1 does not currently have a pressure injury in their right heel, it should be documented and monitored by staff in their care plan. LPA had a conversation with the Licensee regarding the importance to constant monitoring of skin condition due to R1's history (technical violation issued).

Also at approximately 10:15am, resident (R2) care plan indicates that they are two people assist, but R2's physician report (LIC602) dated 5/20/25 reveals that R2 has an ambulatory status and needs assistance with activities of daily living. Although R2's physician report does not indicate that R2 needs two people assistance, LPA reviewed current LIC500 Personnel Report does not reflect two staff on duty at night shift. Per Licensee, R2 was at one point needing two people assistance, but as of today, one staff is able to assist R2 with their ADLs including transferring, Licensee have staff on duty demonstrate to LPA that R2 was able to be assisted by only one staff while R2 was in the dining room, staff transfer them to their bedroom using a wheelchair. LPA instructed Licensee to obtain an updated physician report (LIC602) to have R2's physician determine the current status and needs of R2, because clearly R2 had a change of condition that resulted in R2 is no longer ambulatory.

At approximately 10:30am, LPA/Licensee observed that staff (S1) did not have a TB tuberculosis test on file in their LIC503 Health Screening form dated 2/11/26. Per Licensee, the health appraisal agency that performed the test have not send them the results. However, Type of TB test performed is not marked on the LIC503 form indicating that the test was done.

Licensee submitted updates of the following documents: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500) and copy of Liability insurance. 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.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2026
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 02/12/2026 12:47 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 02/12/2026 at 12:22 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: 02/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(C)
Personal Accommodations and Services
(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observed that washcloths were hanging on the bathroom towel bars for resident use in two resident bathrooms that are shared; LPA observed that the bathrooms didn’t have paper towels for resident use to help ensure sanitary hygiene care for all residents. The licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2026
Plan of Correction
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Licensee agrees to put paper towels in the bathrooms, and will submit LIC9098 self-certification form ensuring compliance with regulation by POC due date to clear the citation.
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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/12/2026 12:47 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 02/12/2026 at 12:22 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: 02/12/2026

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 LPA's review of records, Staff S1 did not have TB test and results included in their Heatch Screening form, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2026
Plan of Correction
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Licensee has agreed to submit staff S1 health screening, including a TB test results by POC due 2/27/26 to clear the citation.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 02/12/2026 12:47 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 02/12/2026 at 12:22 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: 02/12/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(5)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101, Definitions, or bedridden as defined in Health and Safety Code section 1569.72. The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition, or both.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in one out of five residents (R2) needs an updated medical assessment determining ambulatory status after a change of condition which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2026
Plan of Correction
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Licensee to submit an LIC 9098 self certification that medical ssessment were updated reflecting ambulatory status by POC date of 2/27/2026 in order to clear this citation.
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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2026


LIC809 (FAS) - (06/04)
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