496803611-10-17-2024-21-AS-CMAZ-DA6VRJ-20241018164001

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803611
Report Date: 10/17/2024
Date Signed: 10/17/2024 10:11:39 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2024 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20240819125034

FACILITY NAME:	APPLE BLOSSOM GARDENS RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	496803611
ADMINISTRATOR:	BLANCAFLOR,JOSEPHINE		FACILITY TYPE:	740
ADDRESS:	476 EILEEN DR		TELEPHONE:	(707) 829-8539
CITY:	SEBASTOPOL	STATE: CA	ZIP CODE:	95472
CAPACITY:	6	CENSUS: 6	DATE:	10/17/2024
		UNANNOUNCED	TIME BEGAN:	09:02 AM
MET WITH:	Josephine Blancaflor (Licensee)		TIME COMPLETED:	10:20 AM

ALLEGATION(S):

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-Staff are restraining resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Licensee Josephine Blancaflor.

The Department received an allegation of staff are restraining resident in care. Per Reporting party, there was an individual who came to the facility to visit resident (R1), staff (S1) answered the door when S1 recognized the individual, they "looked like a deer in the headlights", immediately turned around and started running into the home, individual ran after S1. S1 had run to where R1 was in their wheelchair and immediately started to take off big, thick belts that were being used to restrain R1 into their wheelchair. S1 said "This is for their safety”. Reporting party ensures that there are no physician's orders for these restraints and that staff should not be doing this. The Reporting Party is very concerned that staff are restraining residents so that they don't have to supervise them as much. LPA conducted an unannounced visit on 8/22/24 and confidential interviews were conducted with Licensee, residents (R1, R2, R3 & R4) and home health nurse. Continues on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024

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 21-AS-20240819125034

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: APPLE BLOSSOM GARDENS RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 496803611
	VISIT DATE: 10/17/2024

NARRATIVE

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Continues from LIC9099...

Based on interviews, there were no concerns been raised related with care and supervision provided by the facility staff including any incident of restraining residents with belts. During the visit, LPA observed some residents do have belts in their wheelchair and inquired about them. According to interviews conducted with staff (S1 & S2), the belts are used as a tool to assist residents with transfers between their wheelchairs to their beds, they are worn around the waist in conjunction with Hoyer lift and the facility have two staff to provide support to the residents in care. LPA conducted confidential interviews with outside parties, who provided a letter dated 7/17/2023 from R1’s responsible party to facility licensee requesting the facility to don’t allow resident from leaving the facility with other people due to medical reasons and requesting staff to supervise R1 when there are more than two people visiting them due to combative behavior after a couple incidents where R1 was observed acting combative after visits. Per Licensee, they are allowing visitors and providing space for them to have privacy, but they do not allow visitors to take R1 out of the facility as indicated per their physician report. Based on records review, LPA have reviewed R1’s physician’s report dated 7/18/23, where it was revealed that R1 does have a motor impairment that needs assistance with activity of daily living (ADLs) and have a non-ambulatory status. Also, has a history of skin breakdown condition, they are not able to leave facility unassisted with family for medical appointments only. R1’s care plan dated 8/16/24 confirms that they are two people assist with transfers. The facility provided LPA with LIC500 Personnel Record and staff schedule for the month of August 2024 revealed that the facility does have two staff per morning and afternoon shift and one staff for night shift to ensure the safety and well-being of residents with mobility challenges. Based on LPA’s observation, there was no information or concern that could revealed that any of the incidents above mentioned have happened at a prior date. A finding that the complaint allegation of staff is restraining resident in care is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
No citations during today's visit.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024

LIC9099 (FAS) - (06/04)

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