015601482-11-5-2024-15-AS-KHOS-DAZHQG-20241114052352

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601482
Report Date: 11/05/2024
Date Signed: 11/05/2024 02:35:15 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/28/2024 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20241028082254

FACILITY NAME:	BLOSSOM GARDEN SENIOR HOME		FACILITY NUMBER:	015601482
ADMINISTRATOR:	HYESUS, FEKERTE		FACILITY TYPE:	740
ADDRESS:	21307 WESTERN BLVD		TELEPHONE:	(510) 363-8566
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	9	CENSUS: 6	DATE:	11/05/2024
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Fekerte Hyesus/Licensee-Administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee is not cashing check payments for resident's (R1) rent and threatening eviction for non-payment.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At 11:50 am on this day, November 5, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with Fekerte Hyesus, licensee-administrator (ADM), and informed the reason for visit.

During the course of investigation, LPA interviewed R1's family member (FM) and ADM. LPA reviewed and obtained copies of R1's records and LIC500 Personnel Report. LPA also reviewed employee roster.

LPA interviewed FM who stated he made an arrangement with the bank for the bank to send payments for monthy rents to ADM. The payment for September 2024 and October 2024 rent were sent by the bank with a returned receipt showing received and signed by A.A. FM stated the licensee told him that the payment was not received and threatened to evict R1. FM stated he cancelled the check and went to the facility in person on Saturday, 10/26/24, and paid the rent for the said months with a cashier's check.
......continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 15-AS-20241028082254

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BLOSSOM GARDEN SENIOR HOME	FACILITY NUMBER: 015601482
	VISIT DATE: 11/05/2024

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
26
27
28
29
30
31
32

LPA interviewed ADM who stated she never received the payments for the September 2024 and October 2024 and there's no staff with initial A.A. ADM stated R1's rent payments were always late 2, 3 days but she understand, because FM lives outside California; however, when she did not receive the payments for September 2024 and October 2024, she called FM but she never mentioned about eviction. ADM confirmed that FM came on October 26, 2024 and gave a cashier's check for September 2024 and October 2024 rent payment.

Based on interviews and review of staff roster and LIC500 Personnel Report showing no staff with A.A. initial, the allegation is closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiency cited.

Exit interview conducted and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2