515002617-4-13-2022-25-AS-KHOS-CDUHUN-20220426063036

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 515002617
Report Date: 04/13/2022
Date Signed: 04/13/2022 10:23:39 AM

Unsubstantiated

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
06/16/2021 and conducted by Evaluator Rebecca Knight

COMPLAINT CONTROL NUMBER: 25-AS-20210616124426

FACILITY NAME:	CHERRY BLOSSOM ASSISTED LIVING		FACILITY NUMBER:	515002617
ADMINISTRATOR:	KNOLL, LORI		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:	04/13/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Melanie Byrd -site supervisor		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility not allowing visitation.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

04/13/2022 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Melanie Byrd, site supervisor for the facility. The purpose of this visit was to deliver the results of the complaint investigation of the above allegation. Prior to initiating the visit, 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 Mask, gloves.

It was reported that the facility was lnot allowing visitation to a resident. -UNSUBSTANTIATED

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

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 2

Control Number 25-AS-20210616124426

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: 04/13/2022

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

During the course of the investigation 1 administrator, 3 staff, and 1 resident were interviewed. LPA obtained the following documents to investigate the above allegation: Durable Power of attorney document, facility visitation policy in regard to Covid 19 restrictions.

Review of Durable Power of attorney document which was notarized on 06/03/2021 revealed that a family member of R1 has durable power of attorney for R1. In the State of California this allows a person to authorize someone else to handle monetary decisions on their behalf. This document has no authoritative power to restrict visitation. The facility’s visitation policy, which is posted at the facility entrance, is specific to restricting visitation due to Covid 19 symptoms or exposure of a visitor in order to protect the residents of the facility.

All staff that were interviewed stated that R1 chose to restrict the visits of a specific individual. R1 chose not to talk on the phone with this individual nor did R1 want this individual to visit them at the facility. Staff stated that this was a family agreement between R1 and the family member. Per the administrator and staff no other visitors were restricted by R1.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are UNSUBSTANTIATED.

An exit interview was conducted. A copy of the report was emailed to site supervisor Melanie Byrd. No deficiencies were cited on today’s date.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2