<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 515002617
Report Date: 08/24/2022
Date Signed: 08/24/2022 11:26:45 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/12/2022 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 25-AS-20220512140645
FACILITY NAME:CHERRY BLOSSOM ASSISTED LIVINGFACILITY NUMBER:
515002617
ADMINISTRATOR:CRAIG VINCELETFACILITY TYPE:
740
ADDRESS:1880 LIVE OAK BLVDTELEPHONE:
(530) 212-8010
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY:79CENSUS: 19DATE:
08/24/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Melanie ByrdTIME COMPLETED:
11:40 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee refused vistation
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kerry Hiratsuka arrived at the facility unannounced to conduct a Complaint Investigation Visit. LPA conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility. LPA was screened by

LPA investigated the allegation “Licensee refused visitation.” LPA Hiratsuka interviewed staff and reviewed past reports created by Community Care Licensing Division (CCLD).

This complaint came in early May 2022. Complaint 25-AS-20220503112603, which had the allegation of “Facility is not allowing residents to have visitors without making an appointment in advance of visits,” was substantiated and delivered on 05/16/2022, which was shortly after this complaint was made. LPA interviewed Melanie Byrd, Residential Services Supervisor (RSS), on 06/02/2022, and RSS stated the facility did at one time require appointments but has since ceased and allows unannounced visits.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
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 6
Control Number 25-AS-20220512140645
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: CHERRY BLOSSOM ASSISTED LIVING
FACILITY NUMBER: 515002617
VISIT DATE: 08/24/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Because the two allegations were made around the same time and one was delivered prior to this one was substantiated, this allegation is also substantiated. However, LPA is not issuing a deficiency because it was already done on 05/15/2022.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/12/2022 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 25-AS-20220512140645

FACILITY NAME:CHERRY BLOSSOM ASSISTED LIVINGFACILITY NUMBER:
515002617
ADMINISTRATOR:CRAIG VINCELETFACILITY TYPE:
740
ADDRESS:1880 LIVE OAK BLVDTELEPHONE:
(530) 212-8010
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY:79CENSUS: 19DATE:
08/24/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Melanie ByrdTIME COMPLETED:
11:40 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
1. Licensee did not ensure resident needs are met
2. Licensee did not ensure resident restricted health plan is met
3. Licensee not meeting resident dietary needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kerry Hiratsuka arrived at the facility unannounced to conduct a Complaint Investigation Visit. LPA conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility. LPA was screened by

LPA investigated the allegation “1. Licensee did not ensure resident needs are met; 2. Licensee did not ensure resident restricted health plan is met; and Licensee not meeting resident dietary needs.” LPA Hiratsuka, interviewed staff and residents. LPA was unable to interview the resident in question. LPA also reviewed resident files.

1 and 2. LPA interviewed staff. Staff stated the former resident in question appeared to be more responsive to some staff over others. They stated the former resident didn’t like to wear the oxygen canula at times or wore it in the mouth instead of the nose. Because LPA is unable to interview the former resident in question, LPA cannot prove or disprove the allegation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 25-AS-20220512140645
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: CHERRY BLOSSOM ASSISTED LIVING
FACILITY NUMBER: 515002617
VISIT DATE: 08/24/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
3. LPA observed lunch and also spoke to residents. The residents had no issues with food, and they stated they get enough to eat. LPA did not observe anyone currently requiring a special diet. LPA was told there is one resident who does require but LPA did not observe that resident eating during LPA's visit. LPA unable to interview former resident in question. LPA cannot prove or disprove the dietary needs are not met based on the above.


Based on the above, because each has their own version of events and LPA is unable to interview the former resident, the allegations are unsubstantiated.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/12/2022 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 25-AS-20220512140645

FACILITY NAME:CHERRY BLOSSOM ASSISTED LIVINGFACILITY NUMBER:
515002617
ADMINISTRATOR:CRAIG VINCELETFACILITY TYPE:
740
ADDRESS:1880 LIVE OAK BLVDTELEPHONE:
(530) 212-8010
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY:79CENSUS: 19DATE:
08/24/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Melanie ByrdTIME COMPLETED:
11:40 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee locks door
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kerry Hiratsuka arrived at the facility unannounced to conduct a Complaint Investigation Visit. LPA conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility. LPA was screened by

LPA investigated the allegation “Licensee Locks Door.” LPA interviewed staff and residents. LPA also toured the facility. The resident interviews stated they are not locked in. The doors are locked from the outside to prevent people from walking in without checking in, but they are not locked to prevent people from getting out. LPA observed the doors to not be locked from the inside during visits.

Based on the interviews, the allegation is unfounded.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 25-AS-20220512140645
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: CHERRY BLOSSOM ASSISTED LIVING
FACILITY NUMBER: 515002617
VISIT DATE: 08/24/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
“This agency has investigated the complaint alleging; Licensee Locks Door. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis."
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6