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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920167
Report Date: 04/09/2025
Date Signed: 04/09/2025 12:12:46 PM

Substantiated


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
04/01/2025 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20250401143759
FACILITY NAME:BLOSSOM RESIDENTIAL IIFACILITY NUMBER:
345920167
ADMINISTRATOR:SOLOVYEV, RALUCAFACILITY TYPE:
740
ADDRESS:8967 AMORUSO AVETELEPHONE:
(916) 254-9557
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 6DATE:
04/09/2025
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Raluca Solovyev, Licensee/AdministratorTIME COMPLETED:
12:25 PM
ALLEGATION(S):
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Facility staff are not treating residents with dignity

Unlawful eviction notice was issued to resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Licensee, Raluca Solovyev, to deliver investigation findings into the complaint allegations listed above.

During the course of the investigation, LPA conducted interviews and review documentation pertinent to the investigation.

The results of the investigation are as follows:

Interview with relevant party indicated that they witnessed staff member (S1) be verbally abusive to resident (R1) and not treat R1 with dignity, including arguing and derogatory statements.

** Report continued on 9099-C **
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
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 4
Control Number 59-AS-20250401143759
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: BLOSSOM RESIDENTIAL II
FACILITY NUMBER: 345920167
VISIT DATE: 04/09/2025
NARRATIVE
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Interview with R1 indicated that they experienced multiple times not being treated with dignity by S1, including arguing and derogatory statements regarding R1. Interview with resident (R2) indicated that they experienced and witnessed S1 not treating the residents with dignity at the care home.

On April 4, 2025, LPA received a recording in which LPA observed staff member (S2) not treating R1 with dignity, including arguing and intimidation. Interview with R1 indicated that they have felt intimidated by facility staff. Interview with Licensee indicated that they received two reports regarding S1 not treating R1 with dignity. Licensee stated that, on March 17, 2025, R1 reported that S1 was "being mean" but wasn't specific how S1 was being mean. Licensee stated that, on March 28, 2025, R1 reported that they were arguing with S1 and S1 argued back with R1 and made derogatory remarks. Licensee stated that S1 quit working at the facility that same day right after being asked about the incident. LPA received an Unusual Incident/Injury Report (SIR) dated March 31, 2025 which states that, on March 28, 2025, "Residents were at the table having lunch. R1 demanded that caregiver assists [them] immediately with a second cup of coffee, while staff was assisting other residents. Caregiver responded that when they are assisting other residents, [R1] will have to be patient and wait, if its not an emergency. Conservation escalated, and R1 started calling the staff inappropriate names."

LPA obtained and reviewed a 30-Day Notice of Termination of Residency given to R1 and authored by Licensee dated March 31, 2015 and given to R1 on March 31, 2025. LPA observed two (2) of multiple reasons listed on the notice to justify termination included the following: "The 602 report did not accurately reflect the level of care required for your needs. We have found that your needs exceed the current care plan, and providing appropriate support has been a challenge...There have been repeated instances of you engaging in disruptive behavior, including outbursts and aggression when staff are unable to immediately attend to your requests." LPA obtained and reviewed R1's Physician's Report (LIC 602A) dated January 15, 2025, which indicated R1 was diagnosed with anxiety disorder and other schizophrenia, and R1 exhibits aggressive behavior including "accusatory behavior, impulsive." LPA obtained and reviewed R1's Preplacement Appraisal Information (LIC 603) dated February 4, 2025, which indicates for Health History to "refer to 602."

LPA observed that the physical address and mail stop code for Community Care Licensing Office to allow the recipient of the notice to file a complaint if desired was incorrect on the notice issued to R1 on March 31, 2025.

** Report continued on 9099-C **
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 59-AS-20250401143759
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: BLOSSOM RESIDENTIAL II
FACILITY NUMBER: 345920167
VISIT DATE: 04/09/2025
NARRATIVE
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Based on interviews conducted, LPA's observations, and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8 and the Health and Safety Code, deficiencies are being cited on the attached 9099-D page.

Exit interview was conducted with Licensee. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 59-AS-20250401143759
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: BLOSSOM RESIDENTIAL II
FACILITY NUMBER: 345920167
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/10/2025
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:
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Facility will conduct an in-service training for all staff regarding residents' personal rights. Facility will submit training information, including date of training and training material, to LPA by POC due date.
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Based on interviews conducted and LPA's observations, the facility did not ensure that residents were treated with dignity when multiple staff exhibited verbally abusive behavior towards residents, which poses an immediate health, safety, and personal rights risk to residents in care.
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Type B
04/24/2025
Section Cited
HSC
1569.683
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§1569.683 Eviction notices; reasons for eviction contents; service (a) In addition to complying with other applicable regulations, a licensee of a residential care facility for the elderly who sends a notice of eviction to a resident (...) shall include all of the following: (3) Information about the resident's right to file a complaint with the department regarding the eviction, with the name, address, and telephone number of the nearest office of community care licensing and the State Ombudsman. This requirement is not met as evidenced by:
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Facility will complete a statement of understanding regarding regulation §1569.683 and submit statement to LPA by POC due date.
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Based on records reviewed, the facility did not ensure that eviction notice issued to resident included the Department's correct address to allow resident to file a complaint, which poses a potential health, safety, and personal rights risk to residents in care.
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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: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025
LIC9099 (FAS) - (06/04)
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