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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002617
Report Date: 11/09/2022
Date Signed: 11/09/2022 03:19:12 PM


Document Has Been Signed on 11/09/2022 03:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



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: DATE:
11/09/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Melanie Byrd, Site SupervisorTIME COMPLETED:
03:30 PM
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
LPA Hiratsuka, conducted this unannounced plan of correction (POC) visit. LPA wore a surgical mask and observed all staff wearing surgical masks.

This visit is a follow-up to citations issued on 10/05/2022, as a result of complaint 25-AS-20220406083937 and case management visit.

Today, LPA cleared the following deficiencies:
-87216(a) Bonding- Licensee failed to obtain a bond when handling resident monies- Today, LPA The management company attempted to submit a statement stating they did not handle any resident monies, except the citation issued is against the licensee because this occurred prior to the management company taking over.

-87216(c) Bonding-Licensee failed to submit an affidavit stating they were going to handle resident monies and they stored and distributed resident monies- Today, LPA is issuing civil penalties because the licensee did not submit any written statement. The management company attempted to submit a statement stating they did not handle any resident monies, except the citation issued is against the licensee because this occurred prior to the management company taking over.

-87207 False Claims- Licensee originally submitted a statement they are not going to handle resident monies when first applied and later started handling resident monies and did not submit any statement to Community Care Licensing Division stating they are. Today, LPA is issuing civil penalties because the licensee did not submit any written statement. The management company attempted to submit a statement stating they did not handle any resident monies, except the citation issued is against the licensee because this occurred prior to the management company taking over.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/09/2022
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
-87208(a) Plan of Operation- Licensee did not submit a written plan of operation regarding handling resident monies.- Today, LPA is issuing civil penalties because the licensee did not submit any written statement. The management company attempted to submit a statement stating they did not handle any resident monies, except the citation issued is against the licensee because this occurred prior to the management company taking over.

Today, LPA is clearing two deficiencies:
-87506(b) Resident Records- The files were missing admission agreements and other required paperwork.- Today, LPA reviewed three resident files and they are complete.
-87217(c)(1) Safeguards for Resident Cash, Personal Property, and Valuables.- Licensee was cited for not keeping accurate records when handing resident monies.- Today, LPA received a written statement from the management company stating they have not handed resident monies and shall not handle any monies and therefore are not going to have any logs.

$2000.00 civil penalties issued and shall accrue each day until the licensee submits the written plan of corrections.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2