361800071-10-19-2022-56-AS-KCLS-CKKNCQ-20221026102103

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361800071
Report Date: 10/19/2022
Date Signed: 10/19/2022 03:20:33 PM

Unfounded

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
08/01/2022 and conducted by Evaluator Bernadette Allen

COMPLAINT CONTROL NUMBER: 56-AS-20220801095248

FACILITY NAME:	BLOSSOM GROVE ALZHEIMER'S SPECIAL CARE CENTER		FACILITY NUMBER:	361800071
ADMINISTRATOR:	SUSIANI HALIUM		FACILITY TYPE:	740
ADDRESS:	11116 NEW JERSEY ST		TELEPHONE:	(909) 335-6660
CITY:	REDLANDS	STATE: CA	ZIP CODE:	92373
CAPACITY:	66	CENSUS: 53	DATE:	10/19/2022
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Susiani Halium -Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility did not correctly refund resident.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Bernadette Allen arrived at the facility unannounced to commence a complaint investigation and deliver the findings for the above complaint allegation. LPA met with Administrator Susiani Halium.

After interviews, record review, and gathering evidence, it was determined that the resident’s funds were refunded. Thus, the allegation that the facility did not correctly refund resident was deemed to be UNFOUNDED. A finding of UNFOUNDED means that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted, and a copy of this report was given to Susiani Halium at the conclusion of the visit.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022

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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