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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002617
Report Date: 12/08/2022
Date Signed: 12/08/2022 01:56:43 PM


Document Has Been Signed on 12/08/2022 01:56 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: 26DATE:
12/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Melanie Byrd, Site SupervisorTIME COMPLETED:
02:05 PM
NARRATIVE
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LPA Hiratsuka, conducted this unannounced case management visit. LPA wore a surgical mask during visit and observed all staff wearing surgical masks.

The purpose of this visit is because Administrator on record Craig Vincelet's administrator's certificate expired on 04/26/2022. He did not submit a renewal for it until 11/21/2022, and it still has not been approved.

Title 22 regulations requires the facility to have an administrator with a current administrator's certificate. LPA is issuing a deficiency due to the certificate being expired. The facility does have a site supervisor, which they are allowed to have a qualified designated substitute.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code. Failure to correct shall result in civil penalties.

Appeal rights given.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022
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


Document Has Been Signed on 12/08/2022 01:56 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2022
Section Cited

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Administrator Certification Requirements. Certificates issued under this section shall be renewed every two (2) years provided the certificate holder has complied with all renewal requirements. This is evidenced by: Licensee failed this by:
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The administrator certificate for Craig Vincelet expired April 26, 2022, and was not put in for renewal until 11/22/2022. It has not been approved yet.
This is a potential risk to the health and safety of the resident.
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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 OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022
LIC809 (FAS) - (06/04)
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