515002617-5-20-2022-25-AS-TORZ-CF22Q4-20220602173519

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 515002617
Report Date: 05/20/2022
Date Signed: 05/20/2022 11:54:27 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
02/01/2022 and conducted by Evaluator Rebecca Knight

COMPLAINT CONTROL NUMBER: 25-AS-20220201091300

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: 22	DATE:	05/20/2022
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Melanie Byrd - Resident Services Supervisor		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff do not provide activities for residents - SUBSTANTIATED

INVESTIGATION FINDINGS:

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05/20/2022 12:00 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Melanie Byrd - Resident Services 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, 9 staff, and 5 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 of menu that is posted in common area, activities calendar for the months of January and February 2022.
Continued on LIC9099-C

Substantiated

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: 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 7

Control Number 25-AS-20220201091300

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 do not provide activities for residents- SUBSTANTIATED

On 4/06/22 and 4/13/2022 LPA Knight entered the facility and observed several residents sitting in wheelchairs in the lobby of the facility on both days. On 4/13/2022 during LPA Knight’s tour of the facility she entered the activity room and there were 2 residents present in the room, both were sitting in wheelchairs. One resident was looking out of the window and the other was working on a craft project. There were no staff in the room conducting activities with the residents.

Records review of January 2022 and February 2022 activities calendar showed a good mix of activities included in the calendars.

Staff interviews revealed that the facility has not been offering as many activities to residents as they used to. 4 of 9 staff stated that the facility does not offer any activities to the residents. 8 of 9 staff stated that the residents are not offered enough activities.

3 of 5 residents stated they do not get enough activities.

Administrator stated We have an assortment of activities, we provide a program calendar with activities. Different things they have not done before and some choose not to participate in.

Based on observation and interviews 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 to the Melanie Byrd - Resident Services Supervisor.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (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 7

Control Number 25-AS-20220201091300

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 87219	1 2 3 4 5 6 7	87219(a)(1)(2)(3)(4)(5) Planned Activities (a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: (1) Socialization, achieved through activities such as group discussion and conversation, recreation, arts, crafts, music and care of pets. (2) Daily living skills/activities which foster and maintain independent functioning. (3) Leisure time activities cultivating personal interests and pursuits, and encouraging leisure-time activities with other residents. (4) Physical activities such as games, sports and exercise which develop and maintain strength, coordination and range of motion. (5) Education, achieved through special classes or activities. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agrees to develop a plan to ensure that residents are offered and encouraged to participate in planned activities on a daily basis, and that staff who are responsible for planning and conducting activities fulfill this requirement daily. If additional staffing is required to ensure that daily activities are fulfilled, the facility must ensure that staffing is adequate to do so.
	8 9 10 11 12 13 14	Based on observation and interviews, it was determined that even though the facility has an activities calendar the residents have not been provided with activities for some time which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	The proof of correction is to be received by LPA Knight by 6/03/2022.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Rebecca Knight	TELEPHONE: (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 7

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
02/01/2022 and conducted by Evaluator Rebecca Knight

COMPLAINT CONTROL NUMBER: 25-AS-20220201091300

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: 22	DATE:	05/20/2022
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Melanie Byrd - Resident Services Supervisor		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Residents are made to sit in a chair for long periods of time - UNSUBSTANTIATED
Unqualified staff administering medication to residents - UNSUBSTANTIATED
Unqualified staff caring for residents - UNSUBSTANTIATED
Facility is not providing residents with nutritious meals - UNSUBSTANTIATED
Staff serve small meal portions to residents - UNSUBSTANTIATED

INVESTIGATION FINDINGS:

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05/20/2022 12:00 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Craig Vincelet administrator 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, 9 staff, and 5 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, activities calendar for the months of January and February 2022.
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: 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 7

Control Number 25-AS-20220201091300

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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Residents are made to sit in a chair for long periods of time- UNSUBSTANTIATED

On 4/06/22 and 4/13/2022 LPA Knight entered the facility and observed several residents sitting in wheelchairs in the lobby of the facility on both days.

6 of 8 staff stated that residents sit for long periods of time in their chairs without doing activities.

During resident interviews 1 resident stated that they sit in their chair for long periods of time, 2 stated they cannot walk so they sit in their chair for long periods of time, 2 stated they do not sit in their chair for long periods of time.

Some residents do sit in their chairs for long periods of time because they cannot ambulate independently. The main issue is that residents are not participating in activities while they are sitting for long periods of time and tend to congregate in the lobby because they have not been doing activities. This issue was substantiated and cited in the aforementioned allegation related to lack of activities.

Unqualified staff administering medication to residents- UNSUBSTANTIATED

During staff interviews it was learned that there are med techs on duty to assist residents with medications and care staff have been trained to safely assist with prescribed medications as needed.

During resident interviews 4 of 5 residents stated that they receive their medications on time. 3 of 5 residents stated they have never been given the wrong medication. 3 of 5 residents stated there are enough staff on duty to fulfill their needs, review of staffing schedules confirmed this statement.

Administrator stated that all staff are trained using Relias which is certified and they also are trained hands on per licensing requirements. Administrator stated that staff determine the amount of medication to give a resident by physicians orders, even a PRN still is given an amount by physician's order.

Continued on LIC9099-C

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (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 7

Control Number 25-AS-20220201091300

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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Unqualified staff caring for residents- UNSUBSTANTIATED

8 of 8 staff stated that all staff have been trained with a combination of online training and hands on job shadow training.

Administrator stated that all staff are trained using Relias which is certified and they also are trained hands on per licensing requirements.

3 of 5 residents stated there are enough staff on duty to fulfill their needs, review of staffing schedules confirmed this statement.

Facility is not providing residents with nutritious meals- UNSUBSTANTIATED

Records review of menus that are posted in the common area of the facility show a good mix of nutritious meals that are offered to the residents.

During staff interviews 8 of 8 staff stated that residents do complain about the quality of food.

During resident interviews 2 of 5 residents stated the food that is served is good, 1 of 5 stated that the vegetables are overcooked, 2 of 5 had no opinion.

Administrator stated Some residents have complaints about what is being served not necessarily the quality.

Continued on LIC9099-C

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (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: 6 of 7

Control Number 25-AS-20220201091300

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 serve small meal portions to residents- UNSUBSTANTIATED

During staff interviews 3 of 8 staff stated residents have never told them they were hungry. It was learned that there are some residents who chose not to eat during the day and staff give them their meals when they are hungry. In addition, snacks are available at all times to residents.

During resident interviews 5 of 5 residents stated that the portions are large enough. 5 of 5 residents stated they have never told staff they were hungry.

Administrator stated A resident will say they are hungry depending on the time. We serve them lunch, dinner etc. and if it is in between time we supply a snack.

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 aMelanie Byrd - Resident Services Supervisor.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (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: 7 of 7