345920078-11-7-2024-59-AS-KHOS-DAWNY6-20241111095213

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345920078
Report Date: 11/07/2024
Date Signed: 11/07/2024 11:00:54 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/14/2024 and conducted by Evaluator Talwinder Bains

COMPLAINT CONTROL NUMBER: 59-AS-20241014174428

FACILITY NAME:	BLOSSOM VALE SENIOR LIVING		FACILITY NUMBER:	345920078
ADMINISTRATOR:	SHANKLIN, DANIELLE		FACILITY TYPE:	740
ADDRESS:	6125 HAZEL AVENUE		TELEPHONE:	(916) 560-1149
CITY:	ORANGEVALE	STATE: CA	ZIP CODE:	95662
CAPACITY:	120	CENSUS: 90	DATE:	11/07/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Business Office Director, Jessica Brass		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff do not accord dignity to resident in care.
Staff speak inappropriately to resident in care.

INVESTIGATION FINDINGS:

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On 11/07/24, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced and met with Business Office Director, Jessica Brass to deliver complaint findings into allegations listed above. LPA explained the purpose of the visit upon arrival.

The department conducted records review ,facility observations and interviews to investigate the complaint.

**Report continued on LIC9099-C**

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

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 4

Control Number 59-AS-20241014174428

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BLOSSOM VALE SENIOR LIVING	FACILITY NUMBER: 345920078
	VISIT DATE: 11/07/2024

NARRATIVE

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** Report continued from 9099...

Allegation- Staff do not accord dignity to resident in care. Staff speak inappropriately to resident in care.-Unfounded

The Department conducted Five (5) residents and Four (4) staff interviews to investigate these allegations during complaint investigation visits on 10/16/24 and 10/30/24. Interviews did not indicate any residents, staff and/or witness observed that staff are not providing privacy to residents in care. Department observed during facility visits that facility staff were attentive to resident’s needs and providing them privacy while taking care of them and during resident’s personal time with families and visitors. During residents’ interviews, residents stated that facility staff are meeting their care needs and did not express any concerns with privacy or dignity. Residents’ interviews indicated that staff were treating all residents with dignity and respect and did not express any issues. Resident’s interviews indicated their satisfaction with staff’s professionalism and did not express any issue with staff were being rough with their care or speaking to them in any inappropriate manner. Staff interviews reflected that staff were treating all residents with respect and dignity and were not speaking inappropriately to any residents. Based on facility tour, interviews and observation, the department found this allegation is to be UNFOUNDED.

Based on the investigation, the preponderance of evidence standards has not been met. Therefore, the above all allegations is found to be UNFOUNDED. A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis.

Exit meeting conducted. A copy of this report has been provided to facility.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/14/2024 and conducted by Evaluator Talwinder Bains

COMPLAINT CONTROL NUMBER: 59-AS-20241014174428

FACILITY NAME:	BLOSSOM VALE SENIOR LIVING		FACILITY NUMBER:	345920078
ADMINISTRATOR:	SHANKLIN, DANIELLE		FACILITY TYPE:	740
ADDRESS:	6125 HAZEL AVENUE		TELEPHONE:	(916) 560-1149
CITY:	ORANGEVALE	STATE: CA	ZIP CODE:	95662
CAPACITY:	120	CENSUS: 90	DATE:	11/07/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Business Office Director, Jessica Brass		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff do not provide adequate care and supervision to resident in care.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

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 4

Control Number 59-AS-20241014174428

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BLOSSOM VALE SENIOR LIVING	FACILITY NUMBER: 345920078
	VISIT DATE: 11/07/2024

NARRATIVE

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**report continued from 9099-A......

Allegation- Staff do not provide adequate care and supervision to resident in care.-Unsubstantiated

The Department conducted interviews with staff and residents and reviewed records to investigate the allegation. Department conducted interviews with Administrator, Five (5) residents and four (4) staff to investigate this allegation. During the interview process it was reported that staff supervise residents twenty-four (24) hours a day and check on residents every two hours to provide residents toilet care needs. It was reported that staff are conscience of keeping the residents clean and dry. Resident’s interviews reflected that staff were providing care per their needs and service plan and there were no issues. LPA toured the facility and facility observed to be clean sanitary and free from odors. LPA did not observe any dirty diapers or smell of urine/feces. Record review reflected that facility has adequate staffing to meet all resident’s needs. It was also noted that facility staff were providing care to residents per their needs and service plan without any issues and keeping documentation records as needed. Staff interviews reflected that they were aware about residents’ care needs as indicated in their Needs And Service Plans and assisting residents accordingly without any issues. Based on this information, this allegation is Unsubstantiated. A finding that a complaint allegation 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.

Exit interview conducted. Copy of the report provided.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

LIC9099 (FAS) - (06/04)

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