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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800071
Report Date: 08/20/2025
Date Signed: 08/20/2025 02:36:01 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/20/2022 and conducted by Evaluator Javier Prieto
COMPLAINT CONTROL NUMBER: 18-AS-20220120085033
FACILITY NAME:BLOSSOM GROVE ALZHEIMER'S SPECIAL CARE CENTERFACILITY NUMBER:
361800071
ADMINISTRATOR:SUSIANI HALIUMFACILITY TYPE:
740
ADDRESS:11116 NEW JERSEY STTELEPHONE:
(909) 335-6660
CITY:REDLANDSSTATE: CAZIP CODE:
92373
CAPACITY:66CENSUS: 42DATE:
08/20/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Cristina Miller, Executive Director TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Due to lack of supervision resident sustained a pressure ulcer while in care
Due to lack of care and supervision resident sustained multiple falls while in care.
Resident's medication is mismanaged by staff.
Resident's personal items are not safeguarded by the facility staff.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to concluded a complaint investigation regarding the above allegations. LPA Prieto met with Executive Director Miller and explained the elements of the complaint.

Allegation #1 - Facility staff #1 (S1), S2 and Executive Director Miller reviewed files for resident #1 (R1) and produced records from a medical facility evaluating R1 with no signs of pressure ulcers.

Allegation #2 - Facility is fully staff. Executive Director Miller provided R1's resident service plan and assessed R1 as a fall risk. Facility staff are directed, and documented, for frequent checks due to fall risk.

Allegation #3 - LPA obtained R1's Centrally Stored Medication chart and Physician's Order to show that R1 is receiving their medications and prescribed.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
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-20220120085033
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: BLOSSOM GROVE ALZHEIMER'S SPECIAL CARE CENTER
FACILITY NUMBER: 361800071
VISIT DATE: 08/20/2025
NARRATIVE
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Allegation #4 - Interview with facility staff stated that resident personal items are being safeguarded. Facility requires resident's, upon admission to the facility, to sign a Client/Resident Personal Property and Valuables form. LPA obtained this document for this investigation. R1 no longer resides at the home and was unable to interview.

Based on the information obtained there is not enough evidence to support the allegations made in this complaint. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed LPA Prieto and Executive Director Miller and a copy was left with the facility.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2