Blossom Valley Care Home 2

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced Required 1 Year visit and met with Ronnie and Maybelline Ubungen, Administrators. LPA announced the purpose of the visit. During visit, LPA toured the facility inside and out. LPA toured the garage area and observed food storage areas and locked cabinets for cleaning supplies. LPA observed the kitchen area and observed locked sharp objects, and cleaning supplies. LPA observed a locked closet in hallway for medication. LPA observed perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA toured three resident bedrooms. Each bedroom had available bedding and clothing storage areas as well as functioning lights. ADM tested the smoke detector in the hallway and found the smoke detector to function properly when tested. LPA toured two out of two resident bathrooms. Each bathroom had available soap and paper towels and functioning lights. The water temperatures in the bathroom sinks measured with thermometer at 115.5 to 118.9 F. LPA toured the outside area and found the exits to be clear of obstructions. LPA observed fire extinguisher was last serviced on 07/06/2026. LPA reviewed Fire and Earthquake log. The last disaster drill was conducted on 04/19/2026 LPA reviewed resident records including Centrally Stored Medication Record (CSMR) for 4 residents. LPA reviewed 3 staff records. 1 out of 4 resident was missing 1 medication on CSMR. No deficiency were cited as per California Code of Regulations Title 22. Technical Violation issued see LIC9102. This report was reviewed with ADM and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 15, 2026

Type of visit: Required - 1 Year

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. 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.the state’s words, verbatim · CDSS document, Jul 29, 2025

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit and met with Administrator (ADM) Ronnie Ubungen. LPA observed 6 residents and 2 staff in the facility. LPA reviewed 3 resident files and 3 staff files. LPA toured the facility inside out with ADM. License, Personal Rights posters, and Administrator Certificate were observed in the facility. Living room, dining room, kitchen, 3 shared resident bedrooms, 1 staff room, 2 restrooms, garage, and laundry room were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Room temperature was observed at 72 degree F. Hot water temperature was observed at 116 degree F. Refrigerator temperature was observed at 40 degree F. Freezer temperature was observed at 0 degree F. all the bedrooms were observed with window screens. Bathrooms were observed with nonskid floor. Fire extinguisher was serviced on 05/21/2024. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. Medications closet was observed locked. Knives closet and detergent closet were observed locked. Flash lights, first aid box and night lights were observed in the facility. Front yard and backyard were inspected. There was no obstruction to block the walkways. The last time the facility conducted the emergency frill is 4/24/2024. No deficiency noted today. Exit interview was conducted with ADM. The report was provided to ADM for signature. A copy of the report was provided to ADM.the state’s words, verbatim · CDSS document, Jul 10, 2024