198603005-2-20-2024-11-AS-SCIS-D2XVMG-20240301153332

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603005
Report Date: 02/09/2024
Date Signed: 02/20/2024 02:36:10 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
04/05/2023 and conducted by Evaluator Pamela Bunker

COMPLAINT CONTROL NUMBER: 11-AS-20230405131608

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:	02/09/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Glenda Perez		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not follow proper eviction procedures

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on February 09, 2024. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with staff Glenda Perez. LPA Bunker explained the purpose of today's visit. The investigation consisted of the following: LPA Bunker interviewed staff 1-5 (S1-S5) and residents (R2-R3). LPA Bunker was unable to interview R1. R1 no longer resides at the facility. LPA Bunker asked questions relevant to the nature of the complaint. LPA Bunker requested and reviewed R1's records. LPA Bunker requested copies of supporting documents. Staff 1-4 (S1-S4) were interviewed regarding the above allegation. The licensee, Administrator, and caregivers stated that R1 received a 60-day eviction notice because R1 failed to follow House Rules. S5 stated she wasn't working at the facility during that time and had limited knowledge of the eviction. S1-S4 stated on 12/01/2022, LPA Lourdes Montoya was contacted and made aware of the 60-day eviction notice for R1, who failed to comply with the facility's written House Rules. R2-R3 stated they were never served an unlawful eviction and were happy living at the facility. See continued LIC9099-C page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024

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-20230405131608

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CHERRY BLOSSOMS ELDERCARE	FACILITY NUMBER: 198603005
	VISIT DATE: 02/09/2024

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

Continued LIC9099-C page 2
*** The original LIC9099-C dated 02/09/2024, is being amended. This revised LIC9099-C dated 02/22/2024, will supersede the original document.***
Investigation revealed the following:
LPA Interviewed staff 1-5 (S1-S5), and residents 2-3 (R2-R3). S1-S4 stated that R1 was issued a 60-day eviction notice in December 2022, for non-compliance with facility house rules. R1 failed to comply with the health and safety of other residents at the property was verbally abusive and not following guidelines at the facility. S1-S4 admitted the facility reported the 60-day eviction to the Community Care Licensing (CCL) office. The licensee has confirmed adherence to Title 22 Regulations concerning the eviction process. Specifically, a 60-day eviction notice was issued to the resident in December 2022, and a detailed letter dated December 22, 2022, was dispatched to a family member of the resident, explaining the grounds for the eviction notice. The licensee stated additionally, communication with LPA Lourdes Montoya was established to ensure awareness of the eviction proceedings. Licensee noted that the correspondence received by the Ombudsman was intended to elucidate the reasons behind the eviction, rather than serve as the eviction notice itself. The licensee has emphasized that the resident voluntarily vacated the premises prior to the eviction date. S1-S4 stated the facility was in compliance with the required procedure, resident and the responsible party for the resident were provided with a written notice 60 days in advance of the proposed eviction date. This notice comprehensively included:
- The specific reasons for eviction, detailed with dates, locations, witnesses, and the context of the circumstances.
- A copy of the resident's current service plan.
- An evaluation of relocation needs.
- A directory of referral agencies.
- Information regarding the legal rights of the resident's representative to request an investigation by the department into the eviction reasons, as stipulated in Section 1569.35.
- Contact details for the local long-term care ombudsman, encompassing both address and phone number. The licensee assures that all steps taken are in full compliance with the established procedures. S1-S4 denied the allegation. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the 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 allegation is deemed unsubstantiated. Copies of the Complaint Investigation Report LIC9099, and LIC9099-C were provided to staff. Exit interview conducted

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2