435294278-7-14-2023-26-AS-RMAO-CU7234-20230728170141

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435294278
Report Date: 07/14/2023
Date Signed: 07/14/2023 01:45:32 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/20/2023 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20230420133725

FACILITY NAME:	BLOSSOM VALLEY CARE HOME, INC.		FACILITY NUMBER:	435294278
ADMINISTRATOR:	RONNIE UBUNGEN		FACILITY TYPE:	740
ADDRESS:	4387 SILVERBERRY DRIVE		TELEPHONE:	(408) 489-9170
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95136
CAPACITY:	6	CENSUS: 5	DATE:	07/14/2023
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	RONNIE UBUNGEN		TIME COMPLETED:	12:32 PM

ALLEGATION(S):

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Facility is neglecting services to resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced complaint Investigation visit to deliver the investigation finding and met with administrator (ADM) Ronnie Ubungen.

On 04/20/2023, the Department received a complaint allegation that the facility is neglecting services to resident in care.

On 04/25/2023, LPA Steve Chang conducted an initial 10-day inspection/investigation, and met with ADM. LPA interviewed ADM, ADM's spouse and 2 staff and conducted inspection of the facility with ADM.

Continued on 9099-C. Page 1 of 2.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

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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Control Number 26-AS-20230420133725

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BLOSSOM VALLEY CARE HOME, INC.	FACILITY NUMBER: 435294278
	VISIT DATE: 07/14/2023

NARRATIVE

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LPA interviewed ADM and staff. ADM and his/her spouse, and 2 staff (S1 and S2) denied R1 was a resident of the facility, nor they previously admitted R1 to the facility. ADM stated that the Local Long Term Care Ombudsman (LTCO) came to the facility to inquire if R1 was at the facility on 4/25/2023. LTCO was notified R1 was not a resident of the facility.

LPA obtained and reviewed list of residents (LIC9020A) as of 1/20/2023, R1’s name is not on the list and the facility was in full capacity with a census of 6 (R2-R7).

Based on the documents reviewed and interviews conducted, R1 is not a resident.

The Department has investigated the above allegation. Based on the investigation, documents reviewed, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

No citations noted at today’s compliant investigation visit. The exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien Chang	TELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023

LIC9099 (FAS) - (06/04)

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