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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 092700822
Report Date: 10/10/2023
Date Signed: 10/10/2023 10:13:07 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/14/2023 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 59-AS-20230814163322
FACILITY NAME:BLISSFUL GARDENFACILITY NUMBER:
092700822
ADMINISTRATOR:SOKIMI, MOTUOMANONOFACILITY TYPE:
740
ADDRESS:4210 PRODUCT DRIVETELEPHONE:
(530) 313-0364
CITY:CAMERON PARKSTATE: CAZIP CODE:
95682
CAPACITY:46CENSUS: 33DATE:
10/10/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator Motu SokimiTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Resident sustained an unexplained fracture while in care.
Facility modified a contract without notifying resident's responsible party.
Facility did not give a copy of the contract to resident's responsible party.
Facility staff did not keep a doorway free of obstruction.
Facility staff did not safeguard resident's personal items.
INVESTIGATION FINDINGS:
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On 10/10/23, Licensing Program Analysts (LPAs) Lavinia Muscan and Cheyenne Ratajczak arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Motu Sokimi.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

**Report continued on 9099-C**
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
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 59-AS-20230814163322
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BLISSFUL GARDEN
FACILITY NUMBER: 092700822
VISIT DATE: 10/10/2023
NARRATIVE
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ALLEGATION: Resident sustained an unexplained fracture while in care.
Based on records reviewed and interviews, R1 has a diagnosis of osteoporosis. On 3/24/23, R1 went to the hospital and was diagnosed with a fifth lumbar vertebra compression fracture which was related to osteopenia. Based on interviews and records review, there is no indication that R1 sustained a fall at the facility resulting in the injury listed above. A review of the medical records indicated that R1’s fracture resulted from medical decline, not trauma or lack of care and supervision by facility. Based on records reviewed it was concluded that compression fractures occurred due to R1’s osteoporosis and fragile bones, therefore the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.
ALLEGATION: Facility modified a contract without notifying resident's responsible party
Based on records reviewed and interviews conducted on 8/16/23 and 9/19/23, there is no evidence of Admission Agreements being changed without notifying residents responsible parties, therefore the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.
ALLEGATION: Facility did not give a copy of the contract to resident's responsible party.
Based on records reviewed and interviews conducted, R1s responsible party did receive an Admission Agreement. The Department observed a signed contract between the responsible party and the facility. Further, the Department was notified by the responsible party that they may have misplaced the Admission Agreement. Therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.
ALLEGATION: Facility staff did not keep a doorway free of obstruction.
Based on facility observation on 8/16/23 and 9/19/23 there was no sign of any doorway being obstructed by anything. Therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.
ALLEGATION: Facility staff did not safeguard resident's personal items.
Regarding safeguarding residents’ belongings this allegation was regarding clothing items and hearing aids. All residents interviewed on 9/19/23 said they always get their own clothes back when laundry is done. If something is missing, there is a certain place where clothes are kept so that residents can look for their lost items. Staff verified that this is the case. Additionally, upon verifying the safeguards form, there were no hearing aids listed on R1’s LIC621, therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.
Exit interview conducted. Copy left with facility Administrator.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia MuscanTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2