198603005-9-19-2023-11-AS-EMAZ-CY7R3N-20231204114011

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603005
Report Date: 09/19/2023
Date Signed: 09/19/2023 01:49:29 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
09/14/2023 and conducted by Evaluator Alfonso Iniguez

COMPLAINT CONTROL NUMBER: 11-AS-20230914103626

FACILITY NAME:	CHERRY BLOSSOMS ELDERCARE		FACILITY NUMBER:	198603005
ADMINISTRATOR:	GARCIA, RONEILIO		FACILITY TYPE:	740
ADDRESS:	1416 FERN AVE		TELEPHONE:	(424) 757-2323
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY:	6	CENSUS: 6	DATE:	09/19/2023
		UNANNOUNCED	TIME BEGAN:	08:54 AM
MET WITH:	Teresa Reyes/Administrator Designee		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Allegation: Staff won't provide resident records to authorized representative

INVESTIGATION FINDINGS:

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On 9/19/2023 LPA Alfonso Iniguez conducted and unannounced complaint visit. LPA Iniguez meet with Teresa Reyes /Administrator Designee. LPA explained the purpose of this visit.

Investigation Consisted of: Physical tour of the facility, interviews with Residents (R#2-R#4), Administrator Designee(A#1), Nurse Practitioner (W#1), Staff (S#1-S#3) and Reporting Party (RP) Power of Attorney for (R#1). LPA obtained and reviewed the following documents: (R#1-R#3) Physicians Report, (R#1-R#3) Medication Administration Record (MAR) for September 2023, (R#1-R#3) Admissions Agreement, (R#1-R#3) Needs and Services Plans, (R#1’s) Updated list of medications at discharge from hospital dated on 9/11/2023 , (R#1) copy of Power of Attorney(Notarized and signed on 2/16/2018), copy of (A#1’s) LVN license( expired on 5/31/2025) and Administrator Certification (expired on 11/20/24), client roster, and staff roster.

Evaluation Report continues LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

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-20230914103626

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: 09/19/2023

NARRATIVE

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The details of the complaint alleged that staff did not provide copies of resident records to their representative.

During the records review, LPA inspected: R#1 Power of Attorney notarized and signed on 2/16/2018. The POA states that RP may request information, records, or other documents regarding R#1’s physical. Mental or emotional health, including but not limited to medical and hospital records and other protected health information as defined by HIPPA. (Health Insurance Portability and Accountability Act). LPA also review R#1’s updated list of home medications at discharge from hospital from 9/11/23. In addition, LPA reviewed (W#1) new medication order with new times.

During an interview with Administrator Designee, (A#1) stated that on 9/14/23 around 9:30 AM, she received a call from one of the facility staff; staff told her that one of the family members (RP) was at the facility yelling and cursing in front of the residents saying, 'they give the wrong medication to (R#1) at the wrong time'. I told the staff I would be coming over to explain (RP) the medications. Then, I arrived at the facility and asked (RP) what they needed. (RP) stated, 'This is about your stupid medication record and your staff performance; I want a specific medication to be given at 6:30 AM, 11:00 AM, and 4:00 PM, and you are not changing the time'. I explained to RP that we were following the doctor's orders from the hospital discharge papers that said AM and PM. LPA asked (A#1) how you determined the time to give the medications when only the order said AM and PM? (A#1) stated that she is a licensed vocational nurse (LVN), and AM and PM mean 8 hours apart to give the medication. (A#1) told (RP) that if they want to provide the medications to (R#1) at the times they want, they need to ask for a doctor's order to change the medication times. (RP) asked (A#1), "You better tell Dr. Butlig to come here and change the medication order now." (A#1) told (RP) that she would call the doctor and tell him about your request. On 9/15/23, a Nurse Practitioner from Dr. Butlig's office (W#1) came to the facility and changed the medication order to the times (RP) wanted. (A#1) stated that at any moment, I did not deny copies of the medication records to (RP); I even let them take a picture of the medication records.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230914103626

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: 09/19/2023

NARRATIVE

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During interviews with staff (S#1-S#3), 3 out 3 stated that they knew the resident's personal rights and the function of a Power of Attorney. Also, 3 out of 3 stated that they have never denied records to residents, residents' Power of Attorney, or their representatives.

During interviews with residents (R#1-R#3), 3 out of 3 stated that they know their rights and can make decisions about themselves. Also, 3 out of 3 stated that they have never been denied a copy of their records before by a staff member.

During an interview with the Nurse Practitioner (W#1), she stated that RP was concerned about the medication time given by the hospital after R#1's discharge from the hospital. (W#1) stated that on 9/15/23, she came to the facility and sat down with (RP) and (R#1) and changed the time for the medication (RP) requested to be changed.

During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation(s).

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted, and a copy of the Complaint Report was given to Teresa Reyes /Administrator Designee.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023

LIC9099 (FAS) - (06/04)

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