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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002224
Report Date: 04/05/2022
Date Signed: 04/05/2022 10:48:50 PM


Document Has Been Signed on 04/05/2022 10:48 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:ALMOND BLOSSOM SENIOR CAREFACILITY NUMBER:
045002224
ADMINISTRATOR:RAMOS, EDUVIJESFACILITY TYPE:
740
ADDRESS:1036 BLACKMUIR COURTTELEPHONE:
(530) 342-1813
CITY:CHICOSTATE: CAZIP CODE:
95926
CAPACITY:6CENSUS: 6DATE:
04/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:01 PM
MET WITH:Katherine Cartwright, Executive DirectorTIME COMPLETED:
11:10 PM
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Licensing Program Analyst (LPA) Jaclyn Avila conducted a case management visit to sister facility ALMOND BLOSSOM SENIOR CARE-BIDWELL HEIGHTS on today's date for the purpose of delivering an Order To Individual of Immediate Exclusion from all facilities and the Order to Licensee/Facility of Immediate Exclusion From Facility. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

During the course of this department's (California Department of Social Services - Community Care Licensing) investigation into the whereabouts of Staff 1 (S1), This department learned S1 was possibly employed by Almond Blossom Senior Care - Bidwell Heights and sister facilities: Almond Blossom Senior Care-Bidwell Heights II and Almond Blossom Senior Care. A search of Guardian revealed S1 was not associated to these facilities. LPA, Licensing Program Manager Laura Munoz and Regional Manager Alycia Berryman contacted administrator Katherine Cartwright via phone. LPA asked if S1 was employed and currently working. Administrator confirmed S1 was employee and was currently working solo at ALMOND BLOSSOM SENIOR CARE-BIDWELL HEIGHTS. Administrator and LPA immediately responded to the facility. LPA Jaclyn Avila personally served S1 with ORDER TO INDIVIDUAL OF IMMEDIATE EXCLUSION FROM LICENSED FACILITIES. S1 acknowledged awareness of the exclusion. S1 gathered belongings and left the facility immediately.

Administrator said Staff 2 (S2) who is administrative staff completed the hiring of S1, who's date of hire is 12/28/2021. S2 attempted to transfer S1 however S2 wasn't able to locate S1 in Guardian. S2 provided S1 with a background packet and requested it be completed. S2 did not wait to confirm if S1 was cleared to work in this department's licensed facilities. Administrator confirmed S1 has worked more than 5 days between date of hire and today's date (4/5/2022). Administrator confirmed S1 has also worked at the two sister facilities.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: ALMOND BLOSSOM SENIOR CARE
FACILITY NUMBER: 045002224
VISIT DATE: 04/05/2022
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LPA Avila handed the Order to Administrator of the Facility of Immediate Exclusion From Facility letter to Katherine Cartwright for each associated facility (#45002503, 45002627 and 45002224) and explained that S1 is not allowed back at the facility.

The following deficiencies were cited per Title 22 of the California Code of Regulation (See 809D). Appeal rights were explained and provided to the facility representative listed above and an Exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. Civil penalties assessed on today's date at $100/day that caregiver worked un-associated to the license. A copy of this report was provided to Administrator.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/05/2022 10:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: ALMOND BLOSSOM SENIOR CARE
FACILITY NUMBER: 045002224

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/06/2022
Section Cited

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87355(e)(1) Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption.

This requirement is not met as evidenced by Interview and observation.
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Licensee failed to obtain a criminal record clearance for 1 of 1 staff. This poses an immediate risk to residents in care.
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Civil Penalties assessed $100/day x 5=$500

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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.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022
LIC809 (FAS) - (06/04)
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