<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603005
Report Date: 12/01/2022
Date Signed: 12/01/2022 04:58:55 PM

Substantiated


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):
1
2
3
4
5
6
7
8
9
Staff did not safeguard residents belonging.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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
Substantiated
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 3
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
INVESTIGATIONS REVEALED:

ALLEGATION: Staff did not safeguard residents belonging.

It is alleged staff did not safeguard residents belonging. Reporting Party reported that R1's bedsheets were missing and staff did not know what happened to them. RP reported the licensee has not replaced the missing beddings. Based on interviews conducted with staff (S1, S2 and S3), R1's family claimed that two (2) sets of R1's beddings were missing. S1-S3 stated they are not aware of the missing beddings. S1 stated he is unsure if the two sets of beddings were listed in R1's LIC 621 (Client/Resident Personal Property and Valuables). S2 stated R1 did not have a completed LIC 621 upon admission. S2 stated R1's family filled out a LIC 621 after the claim of missing beddings. S2 stated she refused to sign the LIC 621 because she never saw the missing items. Based on LPA's interviews, record review and observations, the facility did not ensure R1's belongings were listed in a LIC 621 until there was a claim of missing beddings. Based on LPA’s interviews, observations and record review, there is sufficient evidence to corroborate the above allegation.

Based on LPA observations and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated.

California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted and Appeal Rights was discussed with House Manager Lisa Buencillo. A hard copy of the report and Appeal Rights were 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 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2022
Section Cited
CCR
87217(b)
1
2
3
4
5
6
7
SAFEGUARDS FOR RESIDENT CASH, PERSONAL PROPERTY AND VALUABLES (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator shall review the section cited herein and shall self-certify knowledge and understanding. Administrator shall complete a LIC 621 and shall provide a receipt to R1. Administrator shall submit a POC to CCLD via email to lourdes.montoya@dss.ca.gov by the due date, 12/19/2022.
8
9
10
11
12
13
14
Based on observations, interviews and record reviews, the facility staff failed to take appropriate measures to safeguard R1's personal properties by not accounting R1's belongings and not giving R1 a receipt of all such articles. This poses a potential risk to residents' health, safety and/or personal rights.
8
9
10
11
12
13
14
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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3