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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 515002617
Report Date: 05/20/2022
Date Signed: 05/20/2022 11:24:27 AM

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
01/19/2022 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 25-AS-20220119110536
FACILITY NAME:CHERRY BLOSSOM ASSISTED LIVINGFACILITY NUMBER:
515002617
ADMINISTRATOR:KNOLL, LORIFACILITY TYPE:
740
ADDRESS:1880 LIVE OAK BLVDTELEPHONE:
(530) 212-8010
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY:79CENSUS: 22DATE:
05/20/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Melanie Byrd - Residential Service SupervisorTIME COMPLETED:
11:30 PM
ALLEGATION(S):
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Food service inadequate- SUBSTANTIATED
INVESTIGATION FINDINGS:
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05/20/2022 11:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Melanie Byrd - Residential Service 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.
During the course of the investigation 1 administrator, 10 staff, and 7 residents were interviewed. LPA obtained the following documents to investigate the above allegation: Staff list with phone numbers, resident list, staffing schedules, photographs of a list of residents that require a special diet, photograph aof kitchne menu, photograph of menu that is posted in common area, weekly kitchen menus dated 12/24/21-12/30/21 and 1/07/22-1/13/22, photograph of produce supplies in kitchen.
Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
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 5
Control Number 25-AS-20220119110536
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: 05/20/2022
NARRATIVE
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Food service inadequate- SUBSTANTIATED

During LPA’s tour of the facility LPA observed the menu that was posted in the common area of the facility and the menu that was posted in the kitchen that kitchen staff used to prepare the meals for the week did not match.

During staff interviews it was learned that the residents get a lot of pre-prepped meals, and the facility alternates between the same 2 menus week to week. Staff stated they try to follow the posted menu but usually they don’t have the required ingredients so they make whatever they have on hand. The residents are given a lot of pasta and rice dishes. Residents complain about the quality of the food. 5 of 9 staff stated if a resident requires a diabetic diet the facility accommodates them.

During resident interviews 4 of 7 residents stated they do not like the food that is served.

Interview with administrator revealed that some residents have complaints about what is being served and residents would like an alternative to what is being served. Under the previous management the residents could order whatever they wanted. The new management decided that was not cost efficient and some changes were made so the meals are more consistent. Administrator stated they will alternate the menu for any resident that has a recommendation from their physician for a diabetic diet.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was emailed toMelanie Byrd - Residential Service Supervisor.

SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 25-AS-20220119110536
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: 05/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/03/2022
Section Cited
CCR
87555
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87555(b)(6) General Food Service Requirements
(b)The following food service requirements shall apply (6) In facilities for sixteen (16) persons or more, menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days. Facilities licensed for less than sixteen (16) residents shall maintain a sample menu in their file. Menus shall be made available for review by the residents or their designated representatives and the licensing agency upon request. This requirement was not met as evidenced by:
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Administrator agrees to develop menu's one week in advance, if there are changes to a menu the menu shall be updated and posted in the common area as required.
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Based on observation, interviews and records review, it was determined that the facility did not post a menu as served one week in advance of the meal, the facility is not following the posted menu, which poses a potential health and safety risk to residents in care.
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The proof of correction is to be received by LPA Knight by 6/03/2022.
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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 OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
01/19/2022 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 25-AS-20220119110536

FACILITY NAME:CHERRY BLOSSOM ASSISTED LIVINGFACILITY NUMBER:
515002617
ADMINISTRATOR:KNOLL, LORIFACILITY TYPE:
740
ADDRESS:1880 LIVE OAK BLVDTELEPHONE:
(530) 212-8010
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY:79CENSUS: DATE:
05/20/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Melanie Byrd - Residential Service SupervisorTIME COMPLETED:
11:30 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Staff is not meeting the needs of the residents- UNSUBSTANTIATED
INVESTIGATION FINDINGS:
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3
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5
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05/20/2022 11:30 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Melanie Byrd - Residential Service Supervisor for the facility. The purpose of this visit was to deliver the results of the complaint investigation of the above allegations. 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; contacted administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask, gloves.
During the course of the investigation 1 administrator, 10 staff, and 7 residents were interviewed. LPA obtained the following documents to investigate the above allegations: Staff list with phone numbers, resident list, staffing schedules, photographs of a list of residents that require a special diet, photograph of menu that is posted in common area, weekly kitchen menus dated 12/24/21-12/30/21 and 1/07/22-1/13/22, photograph of produce supplies in kitchen.
Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 25-AS-20220119110536
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: 05/20/2022
NARRATIVE
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Staff is not meeting the needs of the residents- UNSUBSTANTIATED

During staff interviews it was learned that when a resident presses their call button staff responds immediately and if they are already assisting another resident the average response time is one to two minutes.

Resident interviews revealed that staff answer call lights within a few minutes if not immediately after they press their call button.

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

An exit interview was conducted. A copy of the report was emailed to facility administrator Melanie Byrd - Residential Service Supervisor.

SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5