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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435294278
Report Date: 04/03/2026
Date Signed: 04/03/2026 10:36:59 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
03/27/2026 and conducted by Evaluator Simranjit Rai
COMPLAINT CONTROL NUMBER: 26-AS-20260327105535
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: 6DATE:
04/03/2026
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Administrator, Ronnie UbungenTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility did not meet resident's hygiene needs.
Staff allowed resident to be left in soiled clothing for extended periods of time.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced complaint investigation visit. LPA Rai met with Administrator (ADM) Ronnie Ubungen and stated the purpose of today's visit.

It was alleged that resident R1's hygiene needs were not met and resident R1 was left in soiled clothing for extended periods of time.

During visit, LPA Rai interviewed 3 staff (S1-S3) and Administrator (ADM) Ronnie Ubungen. ADM stated resident R1 does not live at the facility. ADM stated they are aware of the allegegations and this is regarding another facility. ADM stated resident R1 was never admitted to the facility. 3 Out of 3 staff (S1-S3) stated resident R1 was not a resident at the facility and they do not recognize the name of resident R1.

Continuation on LIC 9099-C, Page 1 of 2.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2026
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 26-AS-20260327105535
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: BLOSSOM VALLEY CARE HOME, INC.
FACILITY NUMBER: 435294278
VISIT DATE: 04/03/2026
NARRATIVE
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Page 2 of 2.

Based on LIC 9020A Register of Facility Residents - Residential Care Facilities for the Elderly from 01/06/2025, resident R1 was not a resident of the facility.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator, Ronnie Ubungen and a copy of the report was provided. Administrator, Ronnie Ubungen gave verbal authorization for facility staff to sign today's report on their behalf.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2