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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603005
Report Date: 12/01/2022
Date Signed: 12/01/2022 04:56:13 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/28/2022 and conducted by Evaluator Lourdes Montoya
COMPLAINT CONTROL NUMBER: 11-AS-20221128145147
FACILITY NAME:CHERRY BLOSSOMS ELDERCAREFACILITY NUMBER:
198603005
ADMINISTRATOR:GARCIA, RONEILIOFACILITY TYPE:
740
ADDRESS:1416 FERN AVETELEPHONE:
(424) 757-2323
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY:6CENSUS: 6DATE:
12/01/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:LISA BUENCILLOTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff not providing adequate food service to resident in care.

INVESTIGATION FINDINGS:
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On 12/1/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted a 10-day complaint visit at this facility. LPA Montoya called and conducted a risk assessment with Administrator Roneilio Garcia (S1) who confirmed the facility is free of Covid-19 infection. LPA met with House Manager Lisa Buencillo (S2) and Staff Angela Tortona (S3) and LPA explained the purpose of the visit.

The investigation consisted of the following: LPA Lourdes Montoya toured the facility with S2 and S3. LPA observed six (6) residents and two (2) staff during the visit. LPA interviewed Staff (S1) via phone and Staff (S2-S3) in the facility. LPA also interviewed two residents (R1 and R2). However, LPA's attempt to interview four residents (R3-R6) were unsuccessful.

REPORT CONTINUED IN LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
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 2
Control Number 11-AS-20221128145147
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CHERRY BLOSSOMS ELDERCARE
FACILITY NUMBER: 198603005
VISIT DATE: 12/01/2022
NARRATIVE
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INVESTIGATIONS REVEALED:

ALLEGATION: Staff not providing adequate food service to resident in care.

It is alleged staff are not providing adequate food service to resident in care. Reporting Party (RP) reported that for the last three months R1 has not been provided efficient food throughout the day; staff have not provided R1 seconds of food or make him extra food when he asks for more food. RP reported staff would not provide him coffee for breakfast. Based on interviews conducted, R1 and R2 are happy with the food and the food service provided by the staff. Interviews with Staff (S1, S2 and S3) revealed R1 is served with extra food and drinks whenever he requests for more; R1 takes a lot of fruits (apples, bananas, and oranges) from the kitchen and keeps them in his bedroom inside his drawers and they get spoiled and rotten; R1 helps himself and takes food from the refrigerator.LPA observed the facility has sufficient food supplies and observed R1 enjoying his lunch while LPA was visiting the facility. Based on LPA’s interviews, observations and record review, there is no sufficient evidence to corroborate the above allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is Unsubstantiated

An exit interview was conducted with House Manager Lisa Buencillo, and a hard copy of the report was provided.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2