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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700821
Report Date: 08/28/2025
Date Signed: 08/28/2025 09:43:52 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/17/2025 and conducted by Evaluator Cassandra Mikkelson
COMPLAINT CONTROL NUMBER: 59-AS-20250717100855
FACILITY NAME:BLUEBERRY HILL SENIOR LIVING, INC.FACILITY NUMBER:
342700821
ADMINISTRATOR:HAMRIC, KEITHFACILITY TYPE:
740
ADDRESS:3827 OLIVE LANETELEPHONE:
(916) 900-8399
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 3DATE:
08/28/2025
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Latonia Swain, Care staffTIME COMPLETED:
09:50 AM
ALLEGATION(S):
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Staff left residents in a soiled diaper for a long period of time.
Staff did not properly clean a resident in care.
Staff does not ensure that a resident in care is fed.
Staff did not prevent a resident from developing a pressure injury while in care.
Facility is allowing unqualified staff to fill a syringe with medication.
Staff are smoking inside of the facility.
INVESTIGATION FINDINGS:
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Licensed Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced and met with Carestaff Latonia Swain to deliver findings for the above complaint allegation.LPA spoke with Administrator Keith Hamric via phone to discuss findings

During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

*** Report continued on 9099-C***
Unfounded
Estimated Days of Completion: 10
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
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 3
Control Number 59-AS-20250717100855
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BLUEBERRY HILL SENIOR LIVING, INC.
FACILITY NUMBER: 342700821
VISIT DATE: 08/28/2025
NARRATIVE
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Staff left residents in a soiled diaper for a long period of time.

Interviews with residents indicated they feel their incontinence needs are being met by care staff. Interviews with staff indicated that two residents are continent and able to use the restroom with minimal assistance. One resident is incontinent but vocal regarding need to be changed. Interview with Resident R1 indicated that they have no issues with getting assistance with changing after using the restroom. Therefore the allegation staff left residents in a soiled diaper for a long period of time is unfounded.

Staff did not properly clean a resident in care.

Records reviewed indicated that residents in care were receiving proper care and cleaning which was logged on a daily basis. Records indicated that residents were receiving three or four showers per week unless it was declined by resident. Observations indicated that residents were clean and did not present any odors. Interviews with residents indicated that they feel their hygiene needs are being met by staff. Therefore the allegation staff did not properly clean a resident in care is unfounded.

Staff does not ensure that a resident in care is fed.

Interviews conducted with Resident R1, R2 and R3 indicated that they are content with the meals being provided at the facility. Interviews with staff indicated that they will assist residents as needed with meals and offer additional options if the food made at that time was not desired or liked. Observations indicated that there is a variety of food at the facility for resident consumption. Therefore the allegation staff does not ensure that a resident in care is fed is unfounded.

Staff did not prevent a resident from developing a pressure injury while in care.

Interviews with Resident R1 indicated that they stay in bed most of the day but are able to turn themselves and reposition as needed. Interviews with staff and administrator indicated that R1 uses a hoyer lift for transfers out of bed and is able to reposition themselves as needed. Staff assist with changing R1 and have not seen any signs of skin breakdown. Therefore the allegation staff did not prevent a resident from developing a pressure injury while in care is unfounded.

***Report continued on 9099-C2 page

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20250717100855
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BLUEBERRY HILL SENIOR LIVING, INC.
FACILITY NUMBER: 342700821
VISIT DATE: 08/28/2025
NARRATIVE
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Facility is allowing unqualified staff to fill a syringe with medication.

Records reviewed indicated that syringes were being filled by outside agency for resident who was on hospice care. Facility documentation indicates when syringes were being filled and given to resident. Interviews conducted with staff and administrator indicated that hospice agency filled all medications for resident. No staff at the facility were in charge of drawing up medications for residents. Therefore the allegation facility is allowing unqualified staff to fill a syringe with medications is unfounded.

Staff are smoking inside of the facility.

Interviews with staff, administrator and residents all indicated that no individuals smoke within the facility. Observations indicated that there was an ash tray on the back patio of the facility which contained cigarettes. Observations also indicated that there was no odor of smoke within the facility and no physical indications of smoking were seen within the facility. Therefore the allegation staff are smoking inside of the facility is unfounded.

Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted. Copy of report was given to facility.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3