515002617-5-16-2022-25-AS-TORZ-CEJQYH-20220518123510

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 515002617
Report Date: 05/16/2022
Date Signed: 05/16/2022 03:20:54 PM

Substantiated

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
05/03/2022 and conducted by Evaluator Mai Thao

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220503112603

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:	05/16/2022
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Melanie Byrd, Site Supervisor		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility is not allowing residents to have visitors without making an appointment in advance of visits.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Mai Thao and Talwinder Bains, arrived at the facility unannounced on 4/12/2022 to conduct a Complaint Investigation Visit with the above allegations. Prior to visit, LPAs 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. In addition, Staff screened LPA prior to entering the facility.

During today's visit, LPAs delivered findings.

(Continue 9099-C......)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Mai Thao	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022

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-20220503112603

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: 05/16/2022

NARRATIVE

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It was stated in interviews by Staff 1 (S1) that the facility does not allow visitors at the facility unless visitors schedule 72 hours in advanced. S1 also stated that there have been instances when visitors were refused entry because they did not make an appointment. Effective 3/31/2022, visitation limitations are waived, and Licensee shall allow visitation. The Department has investigated this allegation and has found it to be substantiated. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Appeals rights were provided. Exit interview was conducted 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: 05/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20220503112603

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/16/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/17/2022 Section Cited CCR 87468.1(a)(11)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(11) To have their visitors... permitted to visit privately... and without prior notice... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Site Supervisor took down the visitation policy at the front entrance requiring advanced noticed for visitation during the visit. Licensee agrees to submit in a plan to licensing stating how Licensee can ensure that visitation is allowed by 5/24/2022.
	8 9 10 11 12 13 14	Based on observations and interviews, Licensee are refusing visitation without advanced noticed which poses an immediatel health and safety or personal right risks to all residents in care	8 9 10 11 12 13 14	Licensee also agrees to review visitation policy and CCR 87468.1 with staff by 5/24/2022 and agrees to submit in signatures of staff by 5/24/2022.
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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: Mai Thao	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022

LIC9099 (FAS) - (06/04)

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