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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920167
Report Date: 10/27/2025
Date Signed: 10/27/2025 08:06:47 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
10/08/2025 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20251008085349
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: 3DATE:
10/27/2025
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Raluca Solovyev, AdministratorTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff did not follow resident’s prescribed care plan.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Raluca Solovyev, to deliver findings regarding the complaint allegation listed above.

During the investigation, LPA conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Staff did not follow resident’s prescribed care plan.

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

DATE: 10/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2025
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-20251008085349
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: 10/27/2025
NARRATIVE
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Relevant party reported to the department that facility staff were not monitoring resident (R1's) blood sugar as often as they were supposed to, causing R1's blood sugar to increase and resulting in R1's hospitalization. Interview with witness indicated that R1 is Type 1 diabetic. Witness stated that R1 is not capable of administering their own insulin or able to perform their own glucose testing. Witness stated that facility staff did not inform R1's authorized representative timely regarding insulin not working and blood sugar levels increasing. Interviews conducted with Administrators Raluca Solovyev and Alena Tripadush, as well as staff member (S1), indicated that R1 administered their own insulin and performed their own glucose testing. Administrator Tripadush indicated that R1 was tested for blood sugar levels three (3) times a day, while Administrator Solovyev and S1 stated that R1 was tested for blood sugar levels four (4) times a day.

LPA reviewed R1's records at the facility, including Admission Agreement, Medical Assessment, Doctor's Orders, and Blood Sugar Record. R1's Doctor's Orders indicate that R1 is to use a glucose meter, test, strip, and Softclix lancet "to test blood sugar 3 times per day with meals and once nightly as directed." Doctor's Order was dated April 20, 2025. Medical Assessment for R1 dated April 18, 2025 indicates that R1 is not able to administer their own injections and is not able to perform their own glucose testing. R1 was admitted to the facility on May 22, 2025. LPA observed Blood Sugar Record showed that R1 did not receive testing until September 7, 2025. Interview with Administrator Tripadush indicated that the facility started tracking R1's blood sugar in September as they just started using the forms at another facility. Administrator Solovyev stated that the facility started documenting R1's blood sugar levels because they had an appointment and wanted to know what the results were. LPA did not observe any days listed on Blood Sugar Record indicating that R1 received four (4) tests in one (1) day. LPA observed multiple days on R1's Blood Sugar Record in which R1 was test once or twice in one (1) day. LPA observed that there was no restricted health care plan on file for R1.

Based on interviews conducted and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

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

DATE: 10/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20251008085349
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: 10/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/28/2025
Section Cited
CCR
87464(f)(1)
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87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by:
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Facility will create a plan on tasks to be completed when admitting residents with restricted health conditions. Facility will follow created plan when admitting residents with restricted health conditions moving forward. Facility will submit plan to LPA by POC due date of 10/28/2025.
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Based on interviews conducted and records reviewed, the facility did not ensure that resident received assistance with glucose testing in accordance with doctor's orders and assessments, which poses an immediate 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: 10/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2025
LIC9099 (FAS) - (06/04)
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