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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800071
Report Date: 06/06/2025
Date Signed: 06/06/2025 12:58:37 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/16/2021 and conducted by Evaluator Janira Arreola
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210216173433
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: 45DATE:
06/06/2025
UNANNOUNCEDTIME BEGAN:
12:31 PM
MET WITH:Director, Cristina MillerTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Staff improperly transferred resident resulting in resident's death.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility in order to deliver findings for the above allegation. LPA met with Director, Cristina Miller, who was informed of the purpose of the visit. The investigation consisted of interviews and records review.

It was alleged “Staff improperly transferred resident resulting in resident's death.” It was alleged that a resident sustained a fall at the facility when transferring into their unlocked wheelchair. It was alleged the resident broke their back and was transferred into bed by staff causing further internal injuries and the resident’s death (4) months later. The dates and times of the incident, and the name of the resident involved were not provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

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

DATE: 06/06/2025
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 18-AS-20210216173433
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: BLOSSOM GROVE ALZHEIMER'S SPECIAL CARE CENTER
FACILITY NUMBER: 361800071
VISIT DATE: 06/06/2025
NARRATIVE
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The department conducted (2) staff interviews. Interview with (1) administrative staff revealed a similar incident occurred with Resident #1 (R1). Around 2018, R1 sustained an unwitnessed fall where R1 fell out of their wheelchair and staff called 911 immediately. They did not know if staff moved R1 into bed after the fall but identified Staff #1 (S1) and Staff #2 (S2) as witnesses to R1’s fall. R1 was transferred to the hospital and had a back fracture. They did not know the cause of R1’s back fracture. R1 did not return to the facility after the fall.

Interview with R1’s responsible party revealed R1 sustaining a fall at the facility around 06/18/2018. They revealed staff had admitted they forgot to lock R1’s wheelchair, and that S1 gave R1 Medication #1 (M1) for back pain and put R1 in bed after the fall. R1 sustained (3) fractures as a result of the fall and passed away 10/10/2018. LPA made attempted to collect medical records and death report for R1, however none were provided or able to be obtained due to limited information on R1.

Interview with S1 revealed they did not recall R1 or any fall occurring at the facility due to the incident occurring (7) years ago. S1 revealed S2 worked at the facility but did not have any contact information for S2. Records review of incident reports revealed no death reports for R1. No records for R1 were retained at the facility due to the incident occurring (7) years ago.

Therefore, based on interviews and records reviews the allegation that a resident‘s death was caused by an improper transfer is unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time. An exit interview was conducted, and a copy of this report was provided.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

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

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