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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920078
Report Date: 06/20/2024
Date Signed: 06/20/2024 11:27:52 AM


Document Has Been Signed on 06/20/2024 11:27 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
345920078
ADMINISTRATOR:SHANKLIN, DANIELLEFACILITY TYPE:
740
ADDRESS:6125 HAZEL AVENUETELEPHONE:
(916) 560-1149
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:120CENSUS: 92DATE:
06/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Administrator, Danielle ShanklinTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 06/20/24 to conduct a case management to follow up on a recent AWOL at the facility for resident, R1. LPA met with facility Administrator , Danielle Shanklin and explained the purpose of the visit.

The facility submitted a completed Unusual Incident/Injury Report (LIC624) on/around 06/04/24 regarding resident (R1) leaving the facility unattended on 06/03/24, at approximately 6:30 pm. IR stated that R1 got lost while on walk outside the facility after having dinner with their family member around 06:30pm. IR indicated that R1 was found lost on close by street by facility by bystander who notified law enforcement around 07:20pm and R1 was brought back by them uninjured to the facility.

R1's physician's report, dated 02/17/24, indicates that resident has diagnosis of dementia (primary) and cannot leave the facility unassisted. This was first AWOL incident for R1 since admission to the facility.
R1 has been discharged to another facility for higher level of care.

Although no injuries resulted from R1’s AWOL, R1 was unable to leave the facility unassisted. Facility staff did not provide care and supervision to R1 resulting in R1 leaving the facility unassisted therefore violations are cited today per California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies issued are noted on the LIC809D.


Exit interview conducted. Copy of report and appeal rights provided to administrator.



SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/20/2024 11:27 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/21/2024
Section Cited
CCR
87705(c)(4)

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87705- Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by:
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Current Licensee/Administrator will conduct staff training on keeping a closer watch on any residents that may have a tendency for wondering behaviour and document any changes in condition. Documentation of training shall be provided to Department by POC date-06/21/24.
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Based on interviews conducted and record review, facility staff did not provide care and supervision to R1 resulting in R1 leaving the facility unassisted on 06/03/24 which posed an immediate health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
LIC809 (FAS) - (06/04)
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