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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206953
Report Date: 06/29/2022
Date Signed: 06/30/2022 10:11:52 AM

Substantiated


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
01/31/2022 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20220131114428
FACILITY NAME:BLUEBERRY HILLFACILITY NUMBER:
107206953
ADMINISTRATOR:CASTIGADOR, YOLANDAFACILITY TYPE:
740
ADDRESS:7447 N RIVERSIDE DRIVETELEPHONE:
(559) 981-5630
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:6CENSUS: 5DATE:
06/29/2022
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Yolanda CastigadorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Resident sustained pressure injury while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced at the facility to deliver complaint investigation findings. LPA met with and explained the purpose of the visit with Administrator (AD) Yolonda Castigador.

The Department investigated the allegation: Resident sustained pressure injury while in care. Record review of R1’s hospice file and Physician’s Report reveal R1 did not have a pressure injury prior to admission. The resident was admitted to the facility on 1/13/22. Per Hospice Nurse Note dated 1/17/22, resident sustained a pressure ulcer since the previous visit. Based on record review, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED.

The following deficiencies were observed and noted on the attached LIC 809D. All violations that, if not corrected, will have direct and immediate risk to the health, safety or personal rights of clients in care.

A copy of this report, Plan of Correction and Appeal Rights was emailed to ronald.sandone@yahoo.com. An exit interview with AD was conducted.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
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 3
Control Number 24-AS-20220131114428
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BLUEBERRY HILL
FACILITY NUMBER: 107206953
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/30/2022
Section Cited
CCR
87633(b)(6)(A)
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87633 Hospice Care of Terminally Ill Residents (b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee’s responsibilities for implementation of the hospice care plan. (A)The training shall include but not be limited to typical needs of hospice patients, such as turning and incontinence care to prevent skin breakdown, hydration, and infection control.

This requirement was not met as evidenced by:
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Administrator (AD) has agreed to submit a written statement which will include the plan to obtain training for all staff by a Hospice Agency representative. Training will include skin breakdown prevention and how to properly reposition a resident in care. The statement will include the agency that will provide training, date and time.
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Licensee did not ensure that a Current & complete hospice care plan was maintained at the facility which included identification of training needed related to repositioning of R1 to prevent skin breakdown.

This poses an immediate health & safety risk to persons in care.
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The statement will include that the regulation 87633 has been reviewed and understood by AD by 5PM 6/30/2022. A copy of the regulation was provided.

AD will provide a copy of each of the 3 current hospice resident Hospice Plans. AD will also submit proof of training to CCLD by 7/5/2022.
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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.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
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
01/31/2022 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20220131114428

FACILITY NAME:BLUEBERRY HILLFACILITY NUMBER:
107206953
ADMINISTRATOR:CASTIGADOR, YOLANDAFACILITY TYPE:
740
ADDRESS:7447 N RIVERSIDE DRIVETELEPHONE:
(559) 981-5630
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:6CENSUS: DATE:
06/29/2022
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Yolanda CastigadorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff not providing adequate food service
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced at the facility to deliver complaint investigation findings. LPA met with and explained the purpose of the visit with Administrator (AD)Yolanda Castigador.

The Department investigated the allegation: Staff not providing adequate food service. LPA observed staff and residents happily discussing meal options while the staff prepared dinner. There is not a menu available for review and it could not be confirmed what meals were served during the time R1 resided at the facility. During interviews, it was reported that family brought food daily for R1. It cannot be confirmed whether R1 did not care for the food and requested this or if family chose to do so. Based on observations and interviews the allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur.

A copy of this report was emailed to ronald.sandone@yahoo.com. An exit interview was conducted with AD.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3