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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515002617
Report Date: 04/12/2022
Date Signed: 04/12/2022 06:55:06 PM

Document Has Been Signed on 04/12/2022 06:55 PM - It Cannot Be Edited

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
FACILITY NAME:CHERRY BLOSSOM ASSISTED LIVINGFACILITY NUMBER:
515002617
ADMINISTRATOR:CRAIG VINCELETFACILITY TYPE:
740
ADDRESS:1880 LIVE OAK BLVDTELEPHONE:
(530) 212-8010
CITY:YUBA CITYSTATE: CAZIP CODE:
95991
CAPACITY: 79CENSUS: 23DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Melanie Byrd, Site Supervisor TIME COMPLETED:
07:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mai Thao arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain on today's date. LPA met with Melanie Byrd, Site Supervisor. LPA explained the purpose of the visit. Prior to initiating the annual inspection, 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. In addition, Staff screened LPA prior to entering the facility.

LPA toured the facility inside and out with Melanie Byrd, Site Supervisor to ensure health and safety of residents in care. Areas toured include but are not limited to: TV Room, Activity Room, Dining area, 5 resident bedrooms, 5 resident shared bathroom, kitchen, and storage areas. LPA and staff completed the infection control domain during this inspection.

During today's inspection, LPA reviewed 8 of 8 resident files. LPA observed 3 out of 8 residents with a diagnosis of Dementia with no current updated Medical Assessment and Reappraisals on file. Site Supervisor confirmed that those are the current one and has not been updated. LPA observed 2 out of 8 resident without a Appraisal/Needs and Service Plan on file. LPA observed that 1 out of 8 resident Reappraisal was last completed on 2/13/2020. LPA observed 1 out of 8 resident without an Admission Agreement on file. Site Supervisor confirmed that there is not one on file for 1 out of 8 resident. LPA observed 3 of 3 staff files. All 3 out of 3 staff have current first aid on file, but no staff with current CPR training. Site Supervisor confirmed that 3 out of 3 staff does not have CPR training completed on file. LPA observed that all 3 out of 3 staff does not have the required Dementia Training on file. LPA also observed 1 out 3 staff who does not have the required initial training within first four weeks of employment.

(continue 809-C........)
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Mai Thao
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 04/12/2022
NARRATIVE
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LPA reviewed Centrally Stored Medications with Staff 2 (S2). LPA reviewed 5 out of 5 Centrally Stored Medication. Around 12:24pm LPA and staff observed that Resident 1 (R1) has 2 medications that were not logged on Centrally Stored Medication Log. Around 2:10pm LPA observed that Resident 2 (R2) has 1 medication not logged in the Centrally Stored Medication Log. LPA also observed that Resident 3 (R3) has 1 medication not logged on the Centrally Stored Medication Logs. LPA asked for a physician's order for medications that were observed during the inspection and facility did not have any physician's order on file. Site Supervisor and S1 confirmed that the facility does not have any and were all sent to Corporate office. LPA requested for the physician's order to be sent to the facility so LPA can confirmed. Facility staff was not able to provide it to LPA. During the inspection, LPA observed that Staff 1 (S1) is not associated to the facility. LPA confirmed on Licensing Information System Database and Guardian that S1 is not associated to the facility. S1 stated that S1 has been working at the facility since 4/4/2022.

The following deficiencies were cited per Title 22 of the California Code of Regulation (See 809-D). Appeal rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. Civil penalties assessed on today's date at $100/day that S1 worked un-associated to the license. A copy of this report was provided to Site Supervisor, Melanie Byrd, whose signature on this document confirms receipt.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Mai Thao
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 04/12/2022 06:55 PM - It Cannot Be Edited


Created By: Mai Thao On 04/12/2022 at 05:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: CHERRY BLOSSOM ASSISTED LIVING
FACILITY NUMBER: 515002617

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)
87465 Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and record reviews, the licensee did not comply with the section cited above in 3 out of 3 residents with no physician's order for prescribed medications which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/13/2022
Plan of Correction
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Licensee agrees to submit signed physician's order for R1, R2, and R3 prescribed medications by 4/13/2022.
Type A
Section Cited
CCR
87309(a)
87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and interviews, the licensee did not comply with the section cited above, 1 out of 1 kitchen sink cabinet under the sink has disinfectants and cleaning products which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2022
Plan of Correction
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During the inspections, the disinfectants and cleaning products were immediately taken to be locked in the activity closet by staff and are inaccesible to residents in care.
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
LICENSING EVALUATOR NAME:Mai Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022


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Document Has Been Signed on 04/12/2022 06:55 PM - It Cannot Be Edited


Created By: Mai Thao On 04/12/2022 at 05:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: CHERRY BLOSSOM ASSISTED LIVING
FACILITY NUMBER: 515002617

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.626(a)(1)
§1569.626 Training requirements for direct care staff (a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 staff does not have required training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2022
Plan of Correction
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Licensee stated that 3 out of 3 staff will complete the required Dementia Training by 4/19/2022 and agrees submit in proof of training completed to Licensing by 4/19/2022.

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
LICENSING EVALUATOR NAME:Mai Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/12/2022 06:55 PM - It Cannot Be Edited


Created By: Mai Thao On 04/12/2022 at 05:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: CHERRY BLOSSOM ASSISTED LIVING
FACILITY NUMBER: 515002617

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.626(b)
§1569.625 Staff training; legislative findings; contents (b) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 10 hours of training within the first four weeks of employment and four hours annually thereafter. This training shall be administered on the job, or in a classroom setting, or any combination of the two.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 staff did not have 10 hours of training within the first four weeks of employment which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2022
Plan of Correction
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Licensee stated that Licensee will ensure that 1 out of 1 staff completes required 10 hours of training by 4/19/2022. Licensee agrees to submit in a plan of how Licensee can ensure all staff completes required training withing the first four weeks of employment by 4/19/2022.
Type B
Section Cited
HSC
15969.618(c)(3)
§1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited to have at least 1 staff member who has CPR training on duty and on the premises at all times which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2022
Plan of Correction
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Licensee agrees to submit in a statement stating how Licensee can ensure that there is at least one CPR trained staff on duty and on the premises at all times by 4/26/2022. Licensee agrees to submit in copies of CPR training and staff schedule to Licensing by 4/26/2022.
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
LICENSING EVALUATOR NAME:Mai Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/12/2022 06:55 PM - It Cannot Be Edited


Created By: Mai Thao On 04/12/2022 at 06:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: CHERRY BLOSSOM ASSISTED LIVING
FACILITY NUMBER: 515002617

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 3 out of 3 residents did not have updated Medical Assesment and Reappraisals which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/12/2022
Plan of Correction
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Licensee agrees to schedule 3 out of 3 residents by 4/19/2022 to get updated Medical Assessment and submit in updated Medical Assessments and Reappraisal by 5/12/2022.
Type B
Section Cited
CCR
87463(c)
87463 Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 residents without Reappraisals on file and 1 out of 1 resident without current reapprasial which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2022
Plan of Correction
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Licensee agrees to complete reappraisals for 3 out of 3 residents and submit copies to Licensing by 4/26/2022.
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
LICENSING EVALUATOR NAME:Mai Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022


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Page: 6 of 8
Document Has Been Signed on 04/12/2022 06:55 PM - It Cannot Be Edited


Created By: Mai Thao On 04/12/2022 at 06:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: CHERRY BLOSSOM ASSISTED LIVING
FACILITY NUMBER: 515002617

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(a)
87507 Admission Agreements (a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interviews, the licensee did not comply with the section cited above in 1 out of 1 residents who does not have an admission agreement which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2022
Plan of Correction
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Licensee agrees to submit in a copy of signed admission agreements to Licensing by 4/19/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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
LICENSING EVALUATOR NAME:Mai Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 04/12/2022 06:55 PM - It Cannot Be Edited


Created By: Mai Thao On 04/12/2022 at 06:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: CHERRY BLOSSOM ASSISTED LIVING
FACILITY NUMBER: 515002617

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 staff not having a transfer of criminal record clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2022
Plan of Correction
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During the inspection, facility staff submitted documents to LPA to associate/transfer criminal record clearance to the License. *Civil Penalt of $100/day assessed*
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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
LICENSING EVALUATOR NAME:Mai Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022


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