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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107209300
Report Date: 01/27/2025
Date Signed: 02/03/2025 10:36:13 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/11/2024 and conducted by Evaluator Rachel A Bruce
COMPLAINT CONTROL NUMBER: 24-AS-20241011140047
FACILITY NAME:BLOSSOM CREEKS ASSISTED LIVING 2 INC.FACILITY NUMBER:
107209300
ADMINISTRATOR:SAMRA, RAJVINDERFACILITY TYPE:
740
ADDRESS:2770 NORTH BURGAN AVENUETELEPHONE:
(559) 598-9515
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY:6CENSUS: DATE:
01/27/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Sukhwinder Kaur, Caregiver TIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility has pests
Facility staff were not assisting R1 with ADL's
Staff handled resident in a rough manner
Facility did not properly care for residents restricted health condition
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On January 27, 2025, Licensing Program Analyst (LPA) Rachel Bruce conducted an unannounced complaint investigation visit to the facility for the purpose of delivering investigation findings regarding the above allegations. LPA was met by Sukhwinder Kaur, Caregiver who contacted administrator who gave permission to sign the forms.

The Department has investigated the complaints alleging: Facility has pests; staff were not assisting with ADL's; Staff handled a resident roughly, and facility did not properly care for a resident with restricted health condition. Based on the interviews conducted and/or records review the above allegations are found to be UNSUBSTANTIATED. Although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

A copy of this report along with appeal rights will be emailed to Administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Rachel A Bruce
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/11/2024 and conducted by Evaluator Rachel A Bruce
COMPLAINT CONTROL NUMBER: 24-AS-20241011140047

FACILITY NAME:BLOSSOM CREEKS ASSISTED LIVING 2 INC.FACILITY NUMBER:
107209300
ADMINISTRATOR:SAMRA, RAJVINDERFACILITY TYPE:
740
ADDRESS:2770 NORTH BURGAN AVENUETELEPHONE:
(559) 598-9515
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY:6CENSUS: DATE:
01/27/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:TIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not administer residents medications
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On January 27, 2025, Liicensing Program Analyst (LPA) Rachel Bruce conducted an unannounced complaint investigation visit to the facility for the purpose of deliviering the finding on the above allegation.

During the course of this investigation LPA reviewed facility files and conducted interviews relevant to the complaint investigation. It was determined that the above allegation: Facility did not administer medication is UNFOUNDED. LPA did a thourough reveiw/audit of medication dispensed to Resident R1 specifically and found that the medication dispensing log was accurate and matched inventory of medication on hand.

This agency has investigated the complaint alleging medication was not dispensed. It has been found that the allegation is unfounded and have therefore dismissed the complaint.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Rachel A Bruce
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2