336427420-1-12-2023-18-AS-KCLS-CN33R5-20230113172811

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336427420
Report Date: 01/11/2023
Date Signed: 01/12/2023 10:53:34 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/08/2020 and conducted by Evaluator Javier Prieto

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200708143023

FACILITY NAME:	APPLE BLOSSOM HOME		FACILITY NUMBER:	336427420
ADMINISTRATOR:	REYNOLDS, JEREMY		FACILITY TYPE:	740
ADDRESS:	15676 CECIL AVE		TELEPHONE:	(951) 505-6058
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92508
CAPACITY:	6	CENSUS: 0	DATE:	01/11/2023
		ANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Jeremey Reynolds		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff failed to accurately assist with the administration of medication.
Resident fell and broke her shoulder in the presence of staff.
Staff are not meeting the needs of the residents.
Staff forged a doctor's signature.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javier Prieto met with licensee Jeremey Reynolds to on an announced visit to deliver investigative findings for the mentioned allegations. Medical records obtained and reviewed indicate resident #1 (R1) medication was accurately administered as prescribed. Medical records reviewed also indicate that R1 fell and the fall was reported as required and follow up appointment for medical treatment was made. Interview with facility staff revealed that the licensee Reynolds provides training to staff in dispensing of medication to residents and in the proper need and care and supervision. Medical records obtained indicate that R1 arrived to facility (date) on hospice. Review of R1’s and Death Certificate obtained reveal the cause of death to be Congestive Heart Failure. The licensee and staff interviewed denied forging doctors’ signatures on any documents.
Based on the information obtained there is not enough evidence to corroborate the mentioned allegations. Therefore, the allegations are deemed 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.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021

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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