107206795-2-22-2021-24-AS-AXIG-BYJR53-20210224114229

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107206795
Report Date: 02/22/2021
Date Signed: 02/22/2021 12:29:34 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/29/2021 and conducted by Evaluator See Moua

COMPLAINT CONTROL NUMBER: 24-AS-20210129102156

FACILITY NAME:	BLOSSOM CREEKS ASSISTED LIVING		FACILITY NUMBER:	107206795
ADMINISTRATOR:	SAMRA, RAJVINDER K		FACILITY TYPE:	740
ADDRESS:	501 SOUTH APRICOT AVE		TELEPHONE:	(559) 598-9515
CITY:	FRESNO	STATE: CA	ZIP CODE:	93727
CAPACITY:	6	CENSUS: 6	DATE:	02/22/2021
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Rajvinder (Raj) Samra, Administrator		TIME COMPLETED:	09:11 AM

ALLEGATION(S):

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Resident is being assaulted by a staff while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) S. Moua conducted a subsequent complaint inspection on this date. Due to COVID-19 precautionary measures, LPA called and spoke to Administrator Raj. The allegation was discussed and finding was delivered.

The Department interviewed facility staff, hospice, and family. R1 has no bruises or injuries. There were no witnesses to staff hitting R1 as alleged. Based on interviews conducted, a disgruntle staff resigned from the facility and has a personal vendetta against S2, currently working at the facility and referenced in the complaint. The complaint is Unfounded. No deficiency was observed and exit interview was conducted.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Andy Xiong	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: See Moua	TELEPHONE: (559) 650-7904
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2021

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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