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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800071
Report Date: 06/11/2021
Date Signed: 06/11/2021 09:26:43 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/06/2019 and conducted by Evaluator Deborah Mullen
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20191106160206
FACILITY NAME:BLOSSOM GROVE ALZHEIMER'S SPECIAL CARE CENTERFACILITY NUMBER:
361800071
ADMINISTRATOR:TORRES, VICKYFACILITY TYPE:
740
ADDRESS:11116 NEW JERSEY STTELEPHONE:
(909) 335-6660
CITY:REDLANDSSTATE: CAZIP CODE:
92373
CAPACITY:66CENSUS: 49DATE:
06/11/2021
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Susiani Halim, Executive DirectorTIME COMPLETED:
09:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff neglect contributed to resident's death
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Deborah Mullen conducted an unannounced visit to deliver the findings of the above allegation. LPA met with Susiani Halim, Executive Director. The investigation included interviews with staff, and a review of resident 1’s (R1s) medical records and facility file. Due to R1s passing, LPA was unable to interview R1.

The allegation states staff neglect contributed to resident’s death. The investigation revealed R1 was sent to the hospital and admitted on June 11, 2019. R1 remained hospitalized from June 11, 2019 until the time of his/her death on July 31, 2019. A review of R1’s medical records did not indicate the cause of death was related to neglect on behalf of the facility.

Based upon the above stated information the allegation that staff neglect contributed to resident's death is unsubstantiated. An unsubstantiated allegation means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted, and a copy of this report, along with LIC 811 (Confidential Names List) and appeal rights were reviewed and provided to Ms. Halim.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021
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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