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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002617
Report Date: 05/26/2022
Date Signed: 05/26/2022 05:16:03 PM


Document Has Been Signed on 05/26/2022 05:16 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/26/2022 05:12 PM

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

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The purpose of this meeting was to discuss findings from the solvency audit conducted by the Department. This facility was part of the meeting because the management company for this facility is the licensee of the facilities that were involved in the solvency audit.

Present at the meeting were Regional Managers (RM) Brenda White and Alycia Berryman, Licensing Program Managers See Moua, Liza King, Sergiy Pidgimy and Maribeth Senty, Licensing Program Analysts Maja Jensen, Kerry Hiratsku, Mary Garza and Lady Cabrera, Supervising Auditor Jacqueline Juarez and Auditor Diana Chapman.
Licensee Representative for Everwell Facilities included: Dr. Christopher Zubiate, Licensee; Tina Perez, Senior Manager; and Madison Fetyko, Facility Representative.

This meeting is a result of the solvency audit stemming from a complaint received:

• On 01/19/2021 (27-AS-20210119094215) and 01/23/2021 (27-AS-20210123161803) the Sacramento South Regional Office received complaints of financial concerns at the facility and requested a trust audit be conducted by the Department’s audit section.

• On 04/02/2021(24-AS-20210402160438) the Fresno Regional Office received complaint(s) of financial concerns at the facility and requested a trust audit be conducted by the Department’s audit section.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022
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: 05/26/2022
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The Audit findings were as follows:

• Licensee did not properly maintain accountancy for client P&I funds
• Licensee is not distributing P&I to clients
• Licensee is not allowing the residents to leave the facility to purchase items of their choice.
• Licensee did not maintain adequate records for the Wealth Wagon
• The licensee is operating the program as a profit for each individual paying to participate in the program.
• Licensee is not securing all of the client’s cash resources either at the licensed facility or in an authorized financial institution
• The licensee has a surety bond for $5,000. The bond amount is not sufficient to cover the cash resources maintained by the licensee.


There are no citations issued at this time.


LPA Hiratsuka is emailing this report to Administrator for signature and Administrator is sign and email this report by May 28, 2022. LPA Hiratsuka was instructed to have this sent to Administrator of facility by Tina Perez during the online meeting.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2