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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920078
Report Date: 05/06/2025
Date Signed: 05/06/2025 11:10:23 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
04/30/2025 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20250430114336
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: 109DATE:
05/06/2025
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Business Office Director, Jessica Brass TIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not ensure facility is free of mold.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/06/25, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced and met with Business Office Director, Jessica Brass to do complaint investigation into allegations listed above. LPA explained the purpose of the visit upon arrival.

LPA investigated allegation, “Staff does not ensure facility is free of mold. ” LPA interviewed resident ,R1 in which they stated that there was mold in their shower as R1 saw black stuff coming from bathtub during showers. LPA interviewed maintenance staff ,S1, in which he stated that he was not aware about mold in R1s bathroom but saw small crack in shower tub and filled it while LPA and R1 were present. R1 was satisfied with the fixture and will inform maintenance team know if any other issues arises with this matter. LPA toured the facility and did not observe mold in the facility. Due to the conflicting information, LPA finds allegation 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.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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