515002617-4-22-2022-25-AS-MTHO-CDQRP2-20220422131114

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 515002617
Report Date: 04/22/2022
Date Signed: 04/22/2022 01:11:20 PM

Document Has Been Signed on 04/22/2022 01:11 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

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: 23	DATE:	04/22/2022
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Melanie Byrd, Site Supervisor		TIME COMPLETED:	01:15 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	Licensing Program Analyst (LPA) Mai Thao arrived at the facility unannounced to conduct a Plan of Correction (POC) case management and met with Melanie Byrd, Site Supervisor. LPA explained the purpose of the visit. Prior to initiating the case management, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95. In addition, Staff screened LPA prior to entering the facility. On 4/12/2022, LPA cited the facility on CCR 87465(e) and Licensee agreed upon a POC Due Date of 4/13/2022 to submit in sign physician's orders for Resident 1 (R1), Resident 2 (R2), and Resident 3 (R3) medications. Licensee did not ensure that the POC was corrected upon Due Date of 4/13/2022. On today's date, LPA will be assessing a Civil Penalty of $100/day from 4/14/2022-4/21/2022 for this violation. Site Supervisor provided LPA with a sign medication list/order for R1, R2, and R3. POC corrected on 4/22/2022. On 4/12/2022, LPA cited the facility on HSC 1569.626(a)(1) and Licensee agreed upon a POC Due Date of 4/19/2022 for Staff 1 (S1), Staff (S2), and Staff 3 (S3) training. Licensee did not ensure that the POC was corrected upon Due Date of 4/19/2022. On today's date, LPA will be assessing a Civil Penalty of $100/day from 4/20/2022-4/22/2022 for this violation and will continue to accrue until POC is corrected. On 4/12/2022, LPA cited the facility on HSC 1569.626(b) and Licensee agreed upon a POC Due Date of 4/19/2022 for S1. Licensee did not ensure that the POC was corrected upon Due Date of 4/19/2022. On today's date, LPA will be assessing a Civil Penalty of $100/day from 4/20/2022-4/22/2022 for this violation and will continue to accrue until POC is corrected. (Continue 809-C........)

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai Thao	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/22/2022

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On 4/12/2022, LPA cited the facility on CCR 87507(a) and Licensee agreed upon a POC Due Date of 4/19/2022 for Resident 4 (R4) admission agreement. Licensee did not ensure that the POC was corrected upon Due Date of 4/19/2022. On today's date, LPA will be assessing a Civil Penalty of $100/day from 4/20/2022-4/22/2022 for this violation and will continue to accrue until POC is corrected.

Civil Penalties were assessed during this visit for failure to correct the above violations by POC Due Date.
Exit Interview was conducted, Appeal rights were provided, and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai Thao	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC809 (FAS) - (06/04)

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