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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920078
Report Date: 04/22/2025
Date Signed: 04/22/2025 11:57:18 AM

Unsubstantiated


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
03/17/2025 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20250317155218
FACILITY NAME:BLOSSOM VALE SENIOR LIVINGFACILITY NUMBER:
345920078
ADMINISTRATOR:SHANKLIN, DANIELLEFACILITY TYPE:
740
ADDRESS:6125 HAZEL AVENUETELEPHONE:
(916) 560-1149
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:120CENSUS: 105DATE:
04/22/2025
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Administrator, Danielle ShanklinTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff did not keep resident's room clean, sanitary and free of clutter.
Staff did not follow resident's needs and service agreement.
INVESTIGATION FINDINGS:
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On 04/22/25, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced and met with Administrator, Danielle Shanklin 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**
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
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 2
Control Number 59-AS-20250317155218
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: 04/22/2025
NARRATIVE
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***Report continued from 9099.....
Allegation- Staff did not keep resident's room clean, sanitary and free of clutter. UNSUBSTANTIATED. On 03/25/25, Department conducted a tour at the facility and observed the facility to be clean, safe, sanitary, and in good repair. An inspection of the facility was conducted and there was no dirt or smell observed. LPA found the appliances, floors, and other areas to be clean and free from dirt and other debris. Three (3) staff interviews indicated that facility was in good repair and did not report any problems with any housekeeping issues. Staff interviews stated that staff kept facility clean and sanitary. It was learned during complaint investigation that R1 lived at the facility since 08/30/20 till 01/25/25 and R1 was mostly refusing housekeeping services offered by staff and were not allowing staff to clean their bedroom or bathroom. Three (3) residents interviews indicated that there were no issues with facility's housekeeping and maintenance services. Department was not able to interview, resident, R1 as R1 moved out from facility on 01/25/25 so Department was not able to determine which housekeeping services were not met by facility staff during their stay at the facility, therefore this allegation is UNSUBSTANTIATED.

Allegation- Staff did not follow resident's needs and service agreement. UNSUBSTANTIATED.

During investigation, the Department interviewed three (3) residents and three (3) staff and reviewed records to investigate this allegation. Record review indicated that facility kept proper documentation regarding residents’ admission agreement (dated- 08/30/20), needs and service plan and other required components regarding resident’s care per Department’s Regulations. Resident’s interviews reflected that facility was meeting their care needs per their needs and service plan and per admission agreements and there were no problems. Staff interviews indicated that they were aware about residents’ care needs per their needs and service plans and providing care accordingly without any issues. Department was not able to interview, resident, R1 as R1 moved out from facility on 01/25/25 so Department was not able to determine which care and service needs were not met by facility during their stay at facility. Based on gathered information, this allegation was found to be UNSUBSTANTIATED.

A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. 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: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2