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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435294278
Report Date: 11/18/2022
Date Signed: 11/21/2022 08:19:20 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/14/2022 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20220614134717
FACILITY NAME:BLOSSOM VALLEY CARE HOME, INC.FACILITY NUMBER:
435294278
ADMINISTRATOR:RONNIE UBUNGENFACILITY TYPE:
740
ADDRESS:4387 SILVERBERRY DRIVETELEPHONE:
(408) 489-9170
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY:6CENSUS: 5DATE:
11/18/2022
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Ronnie UbungenTIME COMPLETED:
10:59 AM
ALLEGATION(S):
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Facility did not refund of former resident’s paid rent for April and May 2022.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced complaint Investigation visit to deliver the investigation finding and met with administrator (ADM) Ronnie Ubungen.

On 06/14/2022, the Department received a complaint allegation that the facility did not refund of former resident’s paid rent for April and May 2022.

On 06/23/2022, LPA Steve Chang conducted an initial 10-day inspection/investigation, and met with ADM. LPA interviewed ADM, and ADM's spouse. ADM stated that R1’s April and May 2022 rent was not refunded based on their Admission Agreement Refund Policy. During investigation visit, a copy of the facility Admission Agreement was obtained during visit.

Continued on 9099-C. Page 1 of 3.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
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 26-AS-20220614134717
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: BLOSSOM VALLEY CARE HOME, INC.
FACILITY NUMBER: 435294278
VISIT DATE: 11/18/2022
NARRATIVE
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Based on review of R1’s Admission Agreement, it states on page 4 of 10, “The resident is required to stay a minimum of two months. Should the resident leave before the two-month minimum period, the resident agrees to pay the entire monthly fee for the first and second months.” R1’s monthly rent was $4,500 plus an additional $500 a month for hospice care services, a total of $5,000. R1 paid rent for April and May 2022 in the amount of $10,000.

On 6/23/2022, LPA interviewed Administrator (ADM) Ronnie Ubungen and ADM's spouse (S1). ADM stated R1 moved in the facility on 04/01/2022, and subsequently admitted into Hospice Care on 04/12/2022. R1 died on 4/26/2022. R1 was at the facility for 27 days including one day when R1’s family picked-up R1's belongings on 04/27/2022.

During the initial complaint investigation visit, the ADM has decided to refund $5,850.00 a partial refund for April 2022 and a full refund for May 2022. ADM refunded 4 days in April 2022 ($600), and 15 days ($250) in April 2022 of paid for hospice care.

A review of the current Admission Agreement approved by the Department in 2007 (LIC604A with Refund Changes addendum in reference to SB141-Soto and Health and Safety Codes 1569.651 & 1569.665 and 9. Refund Policy, on page 4 of 8) is entirely different from R1’s Admission Agreement.

A review of R1’s Admission Agreement under number #4. Billing and Payment Policy -Monthly Rate, on page 4 of 10, “it states that the facility requires resident to stay a minimum of two months and the first two months is non-refundable with no exceptions and should the resident leave before the two-month minimum period, the resident agrees to pay the entire monthly fees for the first and second months.” In addition, under number #5. Refund Policy, on page 4 of 10, “it states that on any subsequent month, in the event of death or sudden illness where resident will require Skilled Nursing Care, a refund will apply based on the anniversary of the admission date based on the following: If it occurs during the 1st 15 days, ½ of the monthly rate will be refunded and If it occurs on the last 16th days, no refund will be made.”

Continued on 9099-C. Page 2 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 26-AS-20220614134717
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: BLOSSOM VALLEY CARE HOME, INC.
FACILITY NUMBER: 435294278
VISIT DATE: 11/18/2022
NARRATIVE
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Based on interviews, and record reviews, the facility (licensee) has issued or utilized a new Admission Agreement to residents which is subject to Department’s review to ensure it adheres to current policies, regulations and laws on refund policies. A review of R1’s Admission Agreement on page 4 of 10 under #4. Billing and Payment Policy and #5. Refund Policies has conflicting and/or misleading information.

The Department has investigated the above allegation. Based on records reviews, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. Deficiency is being cited. See LIC 9099-D.

Exit interview was conducted with ADM. This report and LIC9099-D were provided to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 26-AS-20220614134717
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BLOSSOM VALLEY CARE HOME, INC.
FACILITY NUMBER: 435294278
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/18/2022
Section Cited
CCR
87507(g)(3)(C)(5)(A)
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Admission Agreements: Any fee that charged prior to or after admission, shall be clearly specified. Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code section 1569.652.
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Licensee ageed and understood to submit a new Admissions Agreement with a clear refund policies that adheres to regulations and/or laws by POC date 11/21/2022.
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This requirement was not met as evidenced by the facility did not refund R1's partial & full refund for April & May 2022 after R1's death. A review of the Admission Agreement on is entirely different from R1's Admission Agreement. Refund Policy has conflicting and/or misleading information.
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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: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4