345920078-7-31-2024-59-AS-LMUZ-D85QGC-20240814120919

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345920078
Report Date: 07/31/2024
Date Signed: 07/31/2024 02:30:43 PM

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
07/17/2024 and conducted by Evaluator Talwinder Bains

COMPLAINT CONTROL NUMBER: 59-AS-20240717092636

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: 98	DATE:	07/31/2024
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Administrator, Danielle Shanklin		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Sewer system is down/backed-up in the kitchen.
Facility is not following pet policy for residents.
Laundry room is not clean and exposed electric wires throughout the facility which pose safety concern.

INVESTIGATION FINDINGS:

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On 07/31/24, 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**

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024

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 3

Control Number 59-AS-20240717092636

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: 07/31/2024

NARRATIVE

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***Report continued from 9099.....

Allegation- Sewer system is down/backed-up in the kitchen. --UNFOUNDED

The Department conducted facility’s observations, record review and interviewed four (4) residents and five (5) staff members to investigate the complaint allegation. Staff interviews indicated that facility’s kitchen had leak in one of the drainpipes which was reported to the Department on 06/24/24. Facility contacted plumbing company who came in on 06/26/24 and fixed the leak. It was also learned that kitchen’s ‘water booster’ machine which is used for cleaning and sanitizing dishware was broken around 07/05/24 and work order was placed on 07/06/24. At this time, facility was waiting for the delivery of the part, and it will be installed by Eco Lab once delivered. Due to this issue, facility was using disposable dishware for residents meals service but meals services were not affected. Facility sewer system was found to be working fine without any issues. Based on all this information, this allegation was found to be UNFOUNDED.

Allegation- Facility is not following pet policy for residents. -UNFOUNDED

The Department conducted facility’s observations, record review and interviewed four (4) residents and five (5) staff members to investigate the complaint allegation. During facility’s tour on 07/18/24, facility was found to be clean and odor free. Record review indicated that per residents’ admission agreement, residents were responsible to take care of their pets and residents were following that policy without any issues. Four (4) residents interviews conducted on 07/18/24 indicated that they were not aware about any issues that facility was not following pet policy. Residents did not report any dog urine or feces at the facility. Five (5) staff interviews conducted on 07/18/24 indicated that there were no issues with any residents’ pets at facility. Staff interview reflected that if residents require any assistance with their pet’s care, they can ask help from staff and staff help them without any problems. Based on this information, this allegation was found to be UNFOUNDED.

**Report continued on LIC9099-C**

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 59-AS-20240717092636

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: 07/31/2024

NARRATIVE

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***Report continued from 9099......

Allegation- Laundry room is not clean and exposed electric wires throughout the facility which pose safety concern. -UNFOUNDED

The Department conducted facility’s observations, record review and interviewed four (4) residents and five (5) staff members to investigate the complaint allegation. During Department visit on 07/18/24, facility ‘s laundry rooms were observed to be clean and organized. Additionally, there were no open electric cords noted at the facility which can be safety concern for residents. Four (4) residents interviews conducted on 07/18/24 indicated that facility has clean Landry room for resident’s use and there were no issues. Resident’s interviews indicated that they did not see any open electric cords at facility. Five (5) staff interviews conducted on 07/18/24 indicated that facility provide clean and sanitary laundry area and there were no problems. Staff interviews reflected that there were no open electric cords at facility which can be safety concern for anyone. Based on this information, this allegation was found 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.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024

LIC9099 (FAS) - (06/04)

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