342700257-3-11-2022-27-AS-KHOS-CCLJN8-20220317071131

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700257
Report Date: 03/11/2022
Date Signed: 03/11/2022 11:49:40 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/17/2021 and conducted by Evaluator Jacob Williams

COMPLAINT CONTROL NUMBER: 27-AS-20210217141552

FACILITY NAME:	BLOSSOM VALE SENIOR LIVING		FACILITY NUMBER:	342700257
ADMINISTRATOR:	GOETZ, ASHLEY		FACILITY TYPE:	740
ADDRESS:	6125 HAZEL AVENUE		TELEPHONE:	(916) 988-7901
CITY:	ORANGEVALE	STATE: CA	ZIP CODE:	95662
CAPACITY:	120	CENSUS: 77	DATE:	03/11/2022
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Ashley Goetz		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility staff charged resident for services not rendered
Facility staff did not advise residents authorized representative of a change in resident's condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jacob Williams arrived unannounced to deliver findings to a complaint received on 03/11/2021. LPA met with Vanessa Rormero, Community Relations Director, and explained purpose of visit. Prior to initiating today's visit, LPA completed required COVID-19 testing protocols, confirmed there are currently no positive Covid-19 diagnoses, and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

During the course of the investigation, LPAs interviewed the Executive Director and Reporting Party, reviewed residents (R1) 602, care plan and admission agreement, R1's invoices for November 2020, December 2020, and January 2021, and charting notes for R1 for November 2020 - January 2021. The results of the investigation are as follows:

Cont on 9099-C..

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob Williams	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

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 5

Control Number 27-AS-20210217141552

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: BLOSSOM VALE SENIOR LIVING	FACILITY NUMBER: 342700257
	VISIT DATE: 03/11/2022

NARRATIVE

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Allegation: Facility staff charged resident for services not rendered. LPA observed invoice dated 1/1/2021 for the billing period of 11/16/2021-12/15/2021. R1 was charged $105 for 15 trays at $7 each tray from 12/3/2021-12/09/2021 (was served a total of 24 trays but facility does not charge for first 9 trays each billing period per facility policy). Executive Director claims if a resident is injured or sick then residents are not charged for tray service, but resident did not report a trip over her chair and did not report being injured, so there was no reason noted for not going to dining room and, thus, R1 was billed. Injury was discovered on 12/08/2021 by staff. R1 was later refunded the full $105 for tray service. In conclusion, the service was rendered from 12/03/2021-12/09/2021, and was later refunded in full.

Allegation: Facility staff did not advise residents authorized representative of a change in resident's condition. LPA reviewed R1 progress notes and sees that on 12/08/2021 med tech "...noticed discoloration and swelling to left ankle/foot. Resident stated she hurt her foot when trying to get out of her chair. AM med tech added resident to alert charting and notified RP." LPA then reviewed email chain between RP and Blossom Vale Wellness Director, with Wellness Director discussing R1s injury "The AM med tech was able to get ice on her ankle and she did take a Tylenol... she is having trays in her room so she is not putting too much pressure on her ankle at this time...". While it is possible that staff knew of R1s injury prior to 12/08/2021, there is no preponderance of evidence to prove it.

Based on information obtained, the Department finds the above allegations to be UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob Williams	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/17/2021 and conducted by Evaluator Jacob Williams

COMPLAINT CONTROL NUMBER: 27-AS-20210217141552

FACILITY NAME:	BLOSSOM VALE SENIOR LIVING		FACILITY NUMBER:	342700257
ADMINISTRATOR:	GOETZ, ASHLEY		FACILITY TYPE:	740
ADDRESS:	6125 HAZEL AVENUE		TELEPHONE:	(916) 988-7901
CITY:	ORANGEVALE	STATE: CA	ZIP CODE:	95662
CAPACITY:	120	CENSUS:	DATE:	03/11/2022
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Ashley Goetz		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility staff are not assisting resident with repairing resident's devices

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob Williams	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 27-AS-20210217141552

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: BLOSSOM VALE SENIOR LIVING	FACILITY NUMBER: 342700257
	VISIT DATE: 03/11/2022

NARRATIVE

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Allegation: Facility staff are not assisting resident with repairing resident's devices. LPA reviewed email correspondence between RP and Blossom Vale staff. On 12/08/2021 Wellness Director recommended RP get a new chair for R1 since hers was now broken. The foot of the chair had been broken and stuck out roughly four inches, which in-part caused R1s injury. On 12/10/2021 RC Willey stated the chair was under warranty and they would send someone out as soon as a time was set up with Blossom Vale. Beginning 12/10/2021 RP attempted to get in touch with somebody from Blossom Vale to schedule a time for RC Willey to come repair R1s chair. RP attempted to speak with the concierge desk, send emails, and phone calls but was never able to get in touch with the Executive Director to schedule a time. On 02/17/2021 a report of Suspected Dependent Adult/Elder Abuse was filed by Sean Weston of California Department of Social Services, Centralized Complaint and Information Bureau. The report stated neglect (including deprivation of goods and services). It was only after this that the facility was able to schedule a time for RC Willey to come repair the chair. On 2/24/2021 RC Willey attempted to repair the chair but needed to order a new part. The broken chair should have been a high priority due to it leading to injury for R1 and due to her daily use of it. It took over two months for repairman to be able to get out to facility.

Based on information obtained, the Department finds the above allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Based on California Code of Regulations, Title 22, Division 6, Chapter 8, one (1) deficiency is being cited.

Exit interview conducted. Appeal rights provided.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob Williams	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 27-AS-20210217141552

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: BLOSSOM VALE SENIOR LIVING	FACILITY NUMBER: 342700257
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/11/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/25/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operations (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Executive Director agrees to following: The Executive Director shall submit a statement of understanding to Title 22 regulation, Section 87303. POC shall be submitted by 3/25/2022.
	8 9 10 11 12 13 14	Based on interviews and email records, facility staff did not assist with scheduling time for chair repairman to come repair residents chair, which poses an immediate health and safety risk for all 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: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob Williams	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5