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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435294278
Report Date: 12/23/2024
Date Signed: 12/23/2024 04:33:57 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
12/18/2024 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20241218141227
FACILITY NAME:BLOSSOM VALLEY CARE HOME, INC.FACILITY NUMBER:
435294278
ADMINISTRATOR:RONNIE UBUNGENFACILITY TYPE:
740
ADDRESS:4387 SILVERBERRY DRIVETELEPHONE:
(408) 489-9170
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY:6CENSUS: 5DATE:
12/23/2024
UNANNOUNCEDTIME BEGAN:
01:02 PM
MET WITH:Ronnie UbungenTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility staff neglected to care for the resident's wounds.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) conducted an unannounced investigation visit and met with Administrator Ronnie Ubungen (ADM).

On 12/18/2024, the Department received a complaint with the allegation that facility staff neglect to care for resident R1's wounds.

LPA toured the facility with ADM. LPA requested the resident roster and LIC 500.

LPA observed 5 residents and 4 staff in the facility.


Continue on LIC9099-C. page 1 of 2.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
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 26-AS-20241218141227
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: BLOSSOM VALLEY CARE HOME, INC.
FACILITY NUMBER: 435294278
VISIT DATE: 12/23/2024
NARRATIVE
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The allegation is that the facility staff did not take care of resident R1's wound resulting in R1 being sent to hospital.

LPA interviewed Administrator (ADM) Ronnie Ubungen. ADM stated the facility does not have R1 as resident and did not admit R1 before.

LAP interviewed house manager Maybelline Ubungen (HM). HM stated the facility never has R1 as resident. HM stated there is a health institute with the similar same Blossom Valley Care Health center around the facility, and there were some similar confusion/mistake occurred before.

LPA interviewed 3 staff. 3 Out of 3 staff stated the facility does not have R1 as resident.

LPA interviewed 5 residents. 5 Out of 5 residents stated R1 is not a resident in the facility.

LPA reviewed resident roster, LPA did not find R1 in the resident roster.

The facility's capacity is 6. LPA observed 5 residents and one empty bed, and did not see any other resident in the facility.

Based on the observation, interview, and records reviewed, R1 is not a resident of the facility.

The Department has investigated the above allegation. Based on the investigation, observation, 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 ManzanoTELEPHONE: (408) 277-1289
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2