515002617-10-5-2022-25-AS-TORZ-CKBURG-20221018154840

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 515002617
Report Date: 10/05/2022
Date Signed: 10/05/2022 02:33:04 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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
04/06/2022 and conducted by Evaluator Kerry Hiratsuka

COMPLAINT CONTROL NUMBER: 25-AS-20220406083937

FACILITY NAME:	CHERRY BLOSSOM ASSISTED LIVING		FACILITY NUMBER:	515002617
ADMINISTRATOR:	CRAIG VINCELET		FACILITY TYPE:	740
ADDRESS:	1880 LIVE OAK BLVD		TELEPHONE:	(530) 212-8010
CITY:	YUBA CITY	STATE: CA	ZIP CODE:	95991
CAPACITY:	79	CENSUS: 24	DATE:	10/05/2022
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Melanie Byrd		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Facility is mishandling resident's personal funds.

INVESTIGATION FINDINGS:

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LPA investigated the allegation “Facility is mishandling resident's personal funds.” LPA Hiratsuka, interviewed staff. LPA was unable to interview the resident in question. LPA also reviewed resident files.

LPA obtained a copy of the LIC 405 RECORD OF CLIENT'S/RESIDENT'S SAFEGUARDED CASH RESOURCES, which had the name of the former resident in question. The form had the resident’s name on it, was blank, the manila envelope was empty which indicates the facility did agree at one point to handle the resident money. This was dated 2019. The facility also had names and logs of other residents at the facility which had entries on it. This showed the facility did at one time handle resident personal money. Interviews indicated the former resident in question did receive personal money to spend from the conservator, but there is no record of it at the facility. Also, the current management company stated they were not going to handle personal funds for residents but didn’t produce any logs of when they received the money and when it was returned.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

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 25-AS-20220406083937

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: CHERRY BLOSSOM ASSISTED LIVING	FACILITY NUMBER: 515002617
	VISIT DATE: 10/05/2022

NARRATIVE

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Because there are no logs that were produced from the facility showing the money was received and returned as well as a blank record of client’s/resident’s safeguarded cash resources that indicated the facility did at one time show they agreed to handle the resident’s money, the allegation is substantiated.

Based on the interviews and facility file regarding the former resident the allegation is substantiated. Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code. Failure to correct shall result in civil penalties.

appeal rights left

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20220406083937

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: CHERRY BLOSSOM ASSISTED LIVING	FACILITY NUMBER: 515002617
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/05/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/04/2022 Section Cited CCR 87217(c)(1)	1 2 3 4 5 6 7	Safeguards for Resident Cash, Personal Property, and Valuables. Every facility shall account for any cash resources entrusted to the care or control of the licensee or facility staff. Cash resources include but are not limited to monetary gifts, tax credits and/or refunds, earnings from employment or workshops,	1 2 3 4 5 6 7	By 11/04/2022, the licensee shall submit a written statement stating whether or not they are going to handle resident cash resources and if so, also obtain a bond. If not then just a statement stating they are not handling resident personal monies. The licensee shall also give each resident and their
	8 9 10 11 12 13 14	and personal and incidental need allowances from funding sources such as SSI/SSP. This requirement is not met as evidenced by: based on observation and interviews, the licensee did handle resident money and did not keep an accurate record of it. This is a potential risk to residents.	8 9 10 11 12 13 14	responsible party a written statement stating the facility shall not accept any resident personal money.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

LIC9099 (FAS) - (06/04)

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