092700822-3-8-2023-25-AS-LMUZ-CPR2M3-20230308163028

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 092700822
Report Date: 03/08/2023
Date Signed: 03/08/2023 11:53:56 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/27/2022 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 25-AS-20221027174134

FACILITY NAME:	BLISSFUL GARDEN		FACILITY NUMBER:	092700822
ADMINISTRATOR:	JENNIFER SCARBERRY		FACILITY TYPE:	740
ADDRESS:	4210 PRODUCT DRIVE		TELEPHONE:	(530) 313-0364
CITY:	CAMERON PARK	STATE: CA	ZIP CODE:	95682
CAPACITY:	25	CENSUS: 26	DATE:	03/08/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Administrator Motu Sokimi		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff shaved resident without resident’s consent.

INVESTIGATION FINDINGS:

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On 03/08/2023, Licensing Program Analysts (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Motu Sokimi. Prior to visit, 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 hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

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**

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

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 8

Control Number 25-AS-20221027174134

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: BLISSFUL GARDEN	FACILITY NUMBER: 092700822
	VISIT DATE: 03/08/2023

NARRATIVE

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Staff shaved resident without resident’s consent.
An investigation has been conducted regarding the above allegation. During an interview S1 stated that they asked R1 what happened to R1’s face. R1 stated that while he was in the shower, S2 dry shaved R1 on their face with no cream, just water. R1 also stated that they were not asked if they wanted to be shaved. Based on interviews conducted, S2 violated R1’s personal rights therefore the allegation above is substantiated. Based on the departments observations, interviews conducted, and record(s) reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be SUBSTANTIATED. California Code of regulations are being cited on the attached LIC9099D.

Exit interview was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents. Appeal rights were provided.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 25-AS-20221027174134

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: BLISSFUL GARDEN	FACILITY NUMBER: 092700822
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/08/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/09/2023 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	By 03/09/2023, all staff shall be trained on treating residents with dignity. A written statement shall be submitted to LPA via email.
	8 9 10 11 12 13 14	Based on statements obtained, facility failed to have staff treat R1 with dignity, which poses an immediate health, safety, and personal rights risk to the residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/27/2022 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 25-AS-20221027174134

FACILITY NAME:	BLISSFUL GARDEN		FACILITY NUMBER:	092700822
ADMINISTRATOR:	JENNIFER SCARBERRY		FACILITY TYPE:	740
ADDRESS:	4210 PRODUCT DRIVE		TELEPHONE:	(530) 313-0364
CITY:	CAMERON PARK	STATE: CA	ZIP CODE:	95682
CAPACITY:	25	CENSUS: 26	DATE:	03/08/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Administrator Motu Sokimi		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff are mishandling resident’s medication.
Staff has not assigned resident a PCP.
Staff is financially abusing resident in care.
Staff is not providing adequate food service to residents in care.
Staff do not meet personnel requirements.

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

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

LIC9099 (FAS) - (06/04)

Page: 4 of 8

Control Number 25-AS-20221027174134

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: BLISSFUL GARDEN	FACILITY NUMBER: 092700822
	VISIT DATE: 03/08/2023

NARRATIVE

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Staff are mishandling resident’s medication.
The department conducted an investigation regarding the allegation above. It has been alleged that staff are administering PRN medications to residents without a physician's order as required. Based on interviews conducted and records reviewed, LPA observed all resident PRN medications have physician orders therefore this allegation is UNFOUNDED. This agency has investigated this complaint. We have found the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.

Staff has not assigned resident a PCP.
An investigation has been conducted regarding the above allegations. Based on Title 22 regulations, Section 87465 (a)(1), the licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. The facility is not required to assign a resident a primary care physician however, during the investigation it was learned that R1 does have a primary care physician. It should be noted that this allegation is not valid as it is not a violation of Title 22 regulations. Based on records review and interviews, the allegation listed above is UNFOUNDED. This agency has investigated this complaint. We have found the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.

Staff is financially abusing resident in care.
An investigation has been conducted regarding the above allegations. Interviews were conducted with residents and staff regarding the allegation. Based on interviews conducted, there is no evidence that any staff at the facility are financially abusing and/or that financial maleficence has occurred therefore the allegation above is UNFOUNDED. This agency has investigated this complaint. We have found the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 8

Control Number 25-AS-20221027174134

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: BLISSFUL GARDEN	FACILITY NUMBER: 092700822
	VISIT DATE: 03/08/2023

NARRATIVE

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Staff is not providing adequate food service to residents in care.
An investigation has been conducted regarding the above allegations. LPAs observed the facility food supply as well as interviewed residents regarding the food service. Based on observation and interviews, the facility keeps the required amount of food supply in the facility. Additionally, resident interviews indicated that residents are satisfied with the food service at the facility and feel that they have enough food to eat at every meal therefore the allegation above is UNFOUNDED. This agency has investigated this complaint. We have found the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.

Staff do not meet personnel requirements.
An investigation was conducted in the above allegation. LPA conducted interviews and reviewed staff files showing that staff have TB and physicals on file. Therefore, the allegation is unfounded. This agency has investigated this complaint. We have found the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/27/2022 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 25-AS-20221027174134

FACILITY NAME:	BLISSFUL GARDEN		FACILITY NUMBER:	092700822
ADMINISTRATOR:	JENNIFER SCARBERRY		FACILITY TYPE:	740
ADDRESS:	4210 PRODUCT DRIVE		TELEPHONE:	(530) 313-0364
CITY:	CAMERON PARK	STATE: CA	ZIP CODE:	95682
CAPACITY:	25	CENSUS: 26	DATE:	03/08/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Administrator Motu Sokimi		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff are not properly trained.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

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

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 25-AS-20221027174134

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: BLISSFUL GARDEN	FACILITY NUMBER: 092700822
	VISIT DATE: 03/08/2023

NARRATIVE

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Staff are not properly trained.
An investigation was conducted in the above allegation. LPA reviewed records and conducted staff interviews regarding staff training. Findings found that staff have received in class and shadow trainings per Title 22 requirements. It was noted that some staff stated they wouldn’t mind more trainings. Although the facility is providing required training, it appears additional training is needed therefore the allegation above is 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 was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

LIC9099 (FAS) - (06/04)

Page: 8 of 8