019200837-8-21-2025-15-AS-YFLS-DKVNBF-20250825101906

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200837
Report Date: 07/15/2025
Date Signed: 08/21/2025 03:15:45 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
11/21/2024 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20241121140929

FACILITY NAME:	CHERRY BLOSSOM RESIDENTIAL CARE INC		FACILITY NUMBER:	019200837
ADMINISTRATOR:	LEUNG, BILLY		FACILITY TYPE:	735
ADDRESS:	241 CHERRY WAY		TELEPHONE:	(510) 276-6003
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	23	CENSUS: 21	DATE:	07/15/2025
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Billy Leung, Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff roughly cleaned resident.
Staff inserted an object into resident’s anus.

INVESTIGATION FINDINGS:

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This is an ammended report. On 7/15/25 at 3:15 p.m. Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver findings for the above allegations. LPA met with Billy Leung, Administrator and explained the purpose of the visit.

During the course of investigation, the Department interviewed R1 and W1. LPA interviewed 3 facility staff, reviewed the Department’s report dated 12/18/24 and reviewed R1’s medical records and facility file. LPA was not able to interview R1 as he passed away on 11/27/24.

R1 was admitted to the facility on 8/01/2013. Documents in R1’s file document that R1 is non-verbal and communicates by writing simple words on a white board or tablet. R1’s most recent physician’s report dated 1/04/24 documents that R1 is incontinent of bladder and bowel and requires staff assistance with daily hygiene tasks.

***report continues on LIC9099***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025

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

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20241121140929

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: CHERRY BLOSSOM RESIDENTIAL CARE INC	FACILITY NUMBER: 019200837
	VISIT DATE: 07/15/2025

NARRATIVE

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***report continues from LIC9099**

On 10/31/24 at 7:30 a.m. facility staff went into R1’s room to get him up for the day and found R1 was unresponsive. 911 was called and R1 was taken to the emergency department and later admitted to the hospital with a diagnosis of sepsis. R1 was discharged from the hospital on 11/15/24 and returned to the facility. On the morning of 11/16/24 staff found R1 unresponsive and called 911. R1 was taken back to the hospital and remained there until his death on 11/27/24.

On 11/18/24 W2 reported via a SOC341 that she interviewed R1 who stated via white board that he was physically hurt in the anus with foreign objects by S2 at the facility.

The Department interviewed W1 who stated that he interviewed R1 at the hospital. R1 confirmed to W1 that he felt something had been inserted in his anus. R1 also stated to W1 that he felt S2 did not mean to hurt him and that he wants to return to the facility.

On 11/25/24 the Department interviewed R1 at the hospital via white board. R1 denied that S2 had ever touched him inappropriately or put “something in him.” R1 became visibly annoyed by the question by furrowing his brow and turned away from Department staff and concluded the interview by writing “thank you” on the white board.

LPA interviewed 3 facility staff: S1, S2 and S3: S2 and S3 were R1’s primary caregivers. All 3 reported that R1 was happy at the facility and never had any complaints about his treatment over the 11 years he lived at the facility. S2 was the staff person who changed R1’s diaper on a daily basis for the last 7 years. S2 stated that R1 never had any issues with the daily routine, and it went smoothly. LPA asked if anything has ever been inserted into R1’s rectum and all 3 replied “no.” LPA also asked S2 if he ever got “rough” while changing R1’s diaper, S2 replied “no, I was always as gentle as I could be with R1.”

This agency has investigated the complaint alleging staff roughly cleaned resident and staff inserted an object into resident’s anus. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted, a copy of this report provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025

LIC9099 (FAS) - (06/04)

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