197610977-6-22-2026-31-AS-ERIS-DVASAV-20260622134259

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610977
Report Date: 06/22/2026
Date Signed: 06/22/2026 01:43:51 PM

Document Has Been Signed on 06/22/2026 01:43 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BLOSSOM LOVE FOR ELDERLY LLC		FACILITY NUMBER:	197610977
ADMINISTRATOR/ DIRECTOR:	NERIA, ROMUEL		FACILITY TYPE:	740
ADDRESS:	43659 HOME PLACE DR.		TELEPHONE:	(661) 341-7594
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY: 6		CENSUS: 0	DATE:	06/22/2026
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:45 AM
MET WITH:	Romuel Neria, Administrator / Applicant		TIME VISIT/ INSPECTION COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Evelin Rios met with Romuel Neria for a Pre-licensing inspection. The facility has 4 bedrooms and 3 bathrooms. Fire clearance was approved on 01/19/2026 for five (5) non ambulatory residents and one (1) bedridden resident in bedroom #1 for a total capacity of 6. Two (2) bedrooms are shared and two (2) are private. There is a dementia plan of care in the Program Design. LPA conducted a physical plant tour of the facility inside and out and the following was observed: Upon entry LPA observed appropriate facility postings. LPA observed the facility to be clean and furniture to be in good repair. LPA did not observe any obstructions throughout the facility. There are two fireplaces with screens. The facility phone was operational. There is a dining table and two sitting areas with enough seating to accommodate the capacity of the facility. The facility will store medication and facility files in a locked cabinet by the dining area. LPA observed a fully stocked first aid kit and an up-to-date manual. In the living room with the television, LPA observed games and puzzles for residents. LPA toured the outside backyard grounds. LPA observed appropriate outdoor furniture with an umbrella for shade. There are no bodies of water. The backyard and front yard are fenced in. LPA toured the kitchen area LPA observed a sufficient amount of food and water supply. LPA observed the sharp knives in a locked kitchen drawer inaccessible to residents. LPA observed cleaning chemicals locked in cabinet under the sink. LPA observed a stove, oven, refrigerator and dishwasher. There is an attached garaged used for storage inaccessible to residents. LIC809 Continued on next page.

NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/22/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2026

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLOSSOM LOVE FOR ELDERLY LLC	FACILITY NUMBER: 197610977
	VISIT DATE: 06/22/2026

NARRATIVE

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The bathrooms were observed clean and supplied with toilet paper, hand soap, and paper towels. The hot water temperature was taken at 12:20 p.m., and measured between 105.6 and 107 degrees Fahrenheit. Showers in all bathrooms have appropriate non-skid mats and grab bars.
The laundry room is not accessible to residents. LPA observed a washer a dryer that appeared operational. LPA observed laundry detergents locked in the laundry room.

LPA observed all bedrooms to be clean with appropriate lighting, and furnished with sufficient closet space, chairs, night stands, dressers and beds. Extra linens were observed in a closet by the bedrooms.

The smoke alarms and carbon monoxide detectors were tested by applicant at 12:23 p.m. and were observed operational. The facility is equipped with two fire doors that closed automatically with the smoke detector was tested. There are four (4) fire extinguishers through out the facility fully charged with purchase date 11/18/2025.

Component III Orientation with the Administrator/Applicant was also conducted during the visit.

Pre-Licensing is complete and the facility has no deficiencies. LPA Rios will notify the Centralized Applications Bureau (CAB) Analyst of the completed Pre-Licensing inspection.

An exit interview was conducted. A copy of this report provided to the applicant.

NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/22/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2026

LIC809 (FAS) - (06/04)

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