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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800071
Report Date: 05/06/2024
Date Signed: 05/06/2024 01:49:17 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
05/01/2024 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240501103534
FACILITY NAME:BLOSSOM GROVE ALZHEIMER'S SPECIAL CARE CENTERFACILITY NUMBER:
361800071
ADMINISTRATOR:SUSIANI HALIMFACILITY TYPE:
740
ADDRESS:11116 NEW JERSEY STTELEPHONE:
(909) 335-6660
CITY:REDLANDSSTATE: CAZIP CODE:
92373
CAPACITY:66CENSUS: 54DATE:
05/06/2024
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Brittany Butts, Resident Care CoordinatorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Unqualified staff administering insulin to residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegation. LPA Prieto met with Resident Care Coordinator Brittany Butts and explained the elements of the complaint. This investigation is based on staff interview and documentation.

Regarding the allegation that unqualified staff administering insulin to residents; LPA Prieto gathered the Medication Administration Records (MAR) logs for the only two (2) residents (R1 & R2) at the facility who are insulin dependant. MAR records for each resident's have insulin are dispensed by staff that are medically qualified to do so. Staff records were obtained indicating staff who are administering insulin are documented electronically
***continued on LIC 9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
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 56-AS-20240501103534
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: 05/06/2024
NARRATIVE
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on the resident's MAR log.

Based on the information obtained there is not enough evidence that unqualified staff administering insulin to residents. Therefore, the allegation is deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Resident Care Coordinator Butts and a copy was left with the facility.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2