Blossom Vale Senior Living

Type of visit: Case Management - Incident

Licensing Program Manager (LPM) Laura Munoz and Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 10/01/26 to do case management visit . LPA,LPM met with Administrator, Danielle Morris and explained the purpose of the visit. Department followed up on Incident Report (IR) sent by facility on 9/9/26 for date -9/2/26 regarding resident, R1 where R1 had a fall in facility vehicle while R1 was returning from doctor’s appointment. IR indicates that per staff, S1, R1 was seated and strapped in their motor scooter while departing from doctor’s office and S1 saw from their rear camera while driving that R1 had fall in the vehicle. S1 pulled the vehicle on the side of the road and called emergency services and R1 was transported to local hospital to get medical care. S1 called the facility and notified them regarding R1s fall incident. IR indicated that R1 sustained neck injuries due to this fall incident and R1 was currently under nursing and rehab care at skilled nursing facility. Based on interviews conducted, S1 did not properly strap R1’s motor scooter in the van as the driver only used 1 securement strap in the rear of the scooter. Department of Transportation/ ADA regulation Section 38.23(d) requires all ADA-compliant buses and vans to have a two-part securement system, one to secure the wheelchair, and a seat belt and shoulder harness for the wheelchair user. Department concluded that R1 sustained injuries due to lack of care and supervision as S1 did not ensure that R1s motor scooter was properly secured and strapped which caused R1 to sustain a serious injury. Based on gathered information, deficiency was cited on LIC-809D page per Title 22 Regulations. Department also issued immediate civil penalty of $500.00 during this visit. Civil penalties shall be assessed if facility does not comply with POC requirements which were issued today. Exit interview conducted, appeal rights and copy of the report left at facility.the state’s words, verbatim · CDSS document, Oct 1, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411 · Plan of correction due date: Oct 2, 2026

87411 Personnel Requirements - General - (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. ....this requirement is not met as evidenced by; Based on gathered information, Department concluded that resident, R1 sustained injuries due to lack of care and supervision from staff, S1 on 9/2/26 which poses immediate health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Oct 1, 2026

Plan of correction: Administrator shall send a letter of understanding of this Regulation and shall conduct staff training for this Regulation. POC due date is 10/02/26.

Type of visit: Case Management - Incident

Licensing Program Manager (LPM) Laura Munoz and Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 10/01/26 to do case management visit . LPA,LPM met with Administrator, Danielle Morris and explained the purpose of the visit. Department received followed incidents reports (LIC624) for residents on 09/24/26 as sent by facility; Resident, R1, reported pain in their right hand on 9/14/26 and was sent to hospital and returned on 9/17/26 with diagnosis of right-hand fracture. Resident, R2 was sent to hospital on 9/12/26 as R2 reported chest pain to staff and R2 returned on same day. Resident, R3 was sent to hospital on 9/12/26 as R3 reported they were feeling unwell to staff and R2 returned on 9/13/26 with new medications orders. Based on gathered information, it was evaluated that facility did not report above incidents to Department as required within required time frame, therefore, deficiency was cited on LIC-809D page per Title 22 Regulations. Civil penalties shall be assessed if facility does not comply with POC requirements which were issued today. Exit interview conducted, appeal rights and copy of the report left at facility.the state’s words, verbatim · CDSS document, Oct 1, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211 · Plan of correction due date: Oct 15, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department [...]: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident [...] (D) Any incident which threatens the welfare, safety or health of any resident [...]..this requirement is not met as evidenced by: Based on records review, it was noted that the facility did not comply with the regulation cited above by not reporting incidents within time frame for residents, R1, R2,R3 which poses a potential health, safety, and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 1, 2026

Plan of correction: Administrator to review section 87211 Reporting Requirements and send a letter of understanding to Community Care Licensing. Additionally, administrator to ensure incident reports are filled out and faxed/reported to CCL within time frame with confirmation. All POC documents are due by 10/15/26.

Type of visit: Case Management - Incident

Licensing Program Analysts (LPA) Talwinder Bains arrived at the facility unannounced on 9/15/26 to do case management visit . LPA met with Administrator, Danielle Morris and explained the purpose of the visit. Department followed up on Incident Report (IR) sent by facility on 9/9/26 for date -9/2/26 regarding resident, R1 where R1 had a fall in facility vehicle while R1 was returning from doctor’s appointment with facility’s staff, S1 around 4.45PM. IR indicates that per S1, R1 was seated and strapped in their motor scooter while departing from doctor’s office and S1 saw from their rear camera while driving that R1 had fall in the vehicle. S1 pulled the vehicle on the side of the road and called emergency services and R1 was transported to local hospital to get medical care. S1 called the facility and notified them regarding R1s fall incident. Facility notified R1s physician, responsible party, and long-term care ombudsman (LTCO) regarding this incident. IR also indicates that R1 had broken neck from this fall incident and they were still at the hospital with unknown discharge plan, Department conducted interview with resident, R1 regarding this incident during today’s visit. LPA requested documents related to this incident and facility will submit all documents by 9/17/26 by 5PM. At this time, this case in under review and department will do follow up as needed. No citations were issued per Title 22 Regulations. Exit interview conducted and copy of the report left at facility.the state’s words, verbatim · CDSS document, Sep 15, 2026

Allegation investigated: Staff did not provide appropriate food service to the resident, resulting in dehydration.

On 8/4/26, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced and met with Administrator, Danielle Morris to do complaint findings into allegations listed above. LPA explained the purpose of the visit upon arrival. The department conducted record review and interviewed staff to investigation above allegation. Staff interviews indicated that resident, R1 was residing at the facility from 01/23/26 till they went to hospital on 7/16/26 after R1 had fall incident and due to overall decline in their health conditions and been moved out to another facility as arranged by R1s family. Staff interviews reflected that R1 was independent with their activities of daily living (ADLs) and did not need any assistance from staff including their meals or fluids intake in any manner. Record review indicated that R1 was living at the facility only for medications management and did not require any assistance with any ADLs including dressing, toileting or eating etc. R1s medical assessment, LIC602, dated-1/9/26 indicated that R1 was diagnosed with MCI and required assistance with medication management only. Based on gathered information, this allegation was UNFOUNDED. A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit meeting conducted. A copy of this report has been provided to facility. Unfoundedthe state’s words, verbatim · CDSS document, Aug 4, 2026 · control 59-AS-20260731092720

Type of visit: Required - 1 Year

On 03/02/26, Licensing Program Analyst (LPA) Talwinder Bains arrived unannounced to conduct the annual inspection. LPA met with Administrator, Danielle Shanklin who assisted LPA with today's visit. LPA toured facility with to ensure the health and safety of residents in care. LPA toured residents rooms, medication room, bathrooms, kitchen, dining room, common areas and activity areas. LPA observed residents in common areas participating in activities and in the dining room having lunch. The facility was found to be clean, safe, sanitary and in good condition. Fire extinguishers are maintained and ready for emergency use. Facility has required food supplies. There are appropriate staff present to meet the needs of residents. Inside temperature was 72-74 degree F. Hot water measured between 106-111 in three different areas at facility was in required range 105-120 degree F. Facility was conducting fire and disaster drills and evacuation chair drills for stairwell per requirement. LPA reviewed ten (10) residents files and six (6) staff files. Staff records reviewed indicated training completed and other required paperwork. Residents files found to have required documentation. LPA observed that medications were secured and were inaccessible to residents. LPA completed the full care tool and no deficiencies were observed or cited per Title 22 Regulations. Exit interview conducted and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Mar 2, 2026

Allegation investigated: Staff does not ensure facility is free of mold.

On 05/06/25, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced and met with Business Office Director, Jessica Brass to do complaint investigation into allegations listed above. LPA explained the purpose of the visit upon arrival. LPA investigated allegation, “Staff does not ensure facility is free of mold. ” LPA interviewed resident ,R1 in which they stated that there was mold in their shower as R1 saw black stuff coming from bathtub during showers. LPA interviewed maintenance staff ,S1, in which he stated that he was not aware about mold in R1s bathroom but saw small crack in shower tub and filled it while LPA and R1 were present. R1 was satisfied with the fixture and will inform maintenance team know if any other issues arises with this matter. LPA toured the facility and did not observe mold in the facility. Due to the conflicting information, LPA finds allegation to be UNSUBSTANTIATED. A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit meeting conducted. A copy of this report has been provided to facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 6, 2025 · control 59-AS-20250430114336

Allegation investigated: Staff did not keep resident's room clean, sanitary and free of clutter. Staff did not follow resident's needs and service agreement.

On 04/22/25, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced and met with Administrator, Danielle Shanklin to deliver complaint findings into allegations listed above. LPA explained the purpose of the visit upon arrival. The department conducted records review ,facility observations and interviews to investigate the complaint. **Report continued on LIC9099-C** Unsubstantiated ***Report continued from 9099..... Allegation- Staff did not keep resident's room clean, sanitary and free of clutter. UNSUBSTANTIATED. On 03/25/25, Department conducted a tour at the facility and observed the facility to be clean, safe, sanitary, and in good repair. An inspection of the facility was conducted and there was no dirt or smell observed. LPA found the appliances, floors, and other areas to be clean and free from dirt and other debris. Three (3) staff interviews indicated that facility was in good repair and did not report any problems with any housekeeping issues. Staff interviews stated that staff kept facility clean and sanitary. It was learned during complaint investigation that R1 lived at the facility since 08/30/20 till 01/25/25 and R1 was mostly refusing housekeeping services offered by staff and were not allowing staff to clean their bedroom or bathroom. Three (3) residents interviews indicated that there were no issues with facility's housekeeping and maintenance services. Department was not able to interview, resident, R1 as R1 moved out from facility on 01/25/25 so Department was not able to determine which housekeeping services were not met by facility staff during their stay at the facility, therefore this allegation is UNSUBSTANTIATED. Allegation- Staff did not follow resident's needs and service agreement. UNSUBSTANTIATED. During investigation, the Department interviewed three (3) residents and three (3) staff and reviewed records to investigate this allegation. Record review indicated that facility kept proper documentation regarding residents’ admission agreement (dated- 08/30/20), needs and service plan and other required components regarding resident’s care per Department’s Regulations. Resident’s interviews reflected that facility was meeting their care needs per their needs and service plan and per admission agreements and there were no problems. Staff interviews indicated that they were aware about residents’ care needs per their needs and service plans and providing care accordingly without any issues. Department was not able to interview, resident, R1 as R1 moved out from facility on 01/25/25 so Department was not able to determine which care and service needs were not met by facility during their stay at facility. Based on gathered information, this allegation was found to be UNSUBSTANTIATED. A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit meeting conducted. A copy of this report has been provided to facility.the state’s words, verbatim · CDSS document, Apr 22, 2025 · control 59-AS-20250317155218

Type of visit: Required - 1 Year

On 01/28/2025 , Licensing Program Analyst (LPA) Talwinder Bains arrived unannounced to conduct the annual inspection. LPA met with Business Office Director, Jessica Brass and Resident Care Director, Chrystal Perez who assisted LPA with today's visit. Currently there are 94 residents of which 3 residents are receiving hospice care. LPA toured facility with to ensure the health and safety of residents in care. LPA toured residents rooms, medication room, bathrooms, kitchen, dining room, common areas and activity areas. LPA observed residents in common areas participating in activities and in the dining room having lunch. The facility was found to be clean, safe, sanitary and in good condition. LPA observed the facility to have the mandated posters posted. Fire extinguishers are maintained and ready for emergency use. Facility has required food supplies. There are appropriate staff present to meet the needs of residents. Inside temperature was 72-74 degree F. Hot water measured between 110-114 in three different areas at facility was in required range 105-120 degree F. Facility was conducting fire and disaster drills per requirement. LPA reviewed ten (10) residents files and eight (8) staff files. Staff records reviewed indicated training completed and other required paperwork. Residents files found to have required documentation. LPA reviewed two (2) residents medications comparing with current physician orders and found it to be correct. LPA checked the current narcotic medications log with staff and found no errors. LPA observed that medications were secured and were inaccessible to residents. LPA completed the full care tool and no deficiencies were observed or cited per Title 22 Regulations. Exit interview conducted and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Jan 28, 2025

Allegation investigated: Staff do not accord dignity to resident in care. Staff speak inappropriately to resident in care.

On 11/07/24, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced and met with Business Office Director, Jessica Brass to deliver complaint findings into allegations listed above. LPA explained the purpose of the visit upon arrival. The department conducted records review ,facility observations and interviews to investigate the complaint. **Report continued on LIC9099-C** Unfounded ** Report continued from 9099... Allegation- Staff do not accord dignity to resident in care. Staff speak inappropriately to resident in care.-Unfounded The Department conducted Five (5) residents and Four (4) staff interviews to investigate these allegations during complaint investigation visits on 10/16/24 and 10/30/24. Interviews did not indicate any residents, staff and/or witness observed that staff are not providing privacy to residents in care. Department observed during facility visits that facility staff were attentive to resident’s needs and providing them privacy while taking care of them and during resident’s personal time with families and visitors. During residents’ interviews, residents stated that facility staff are meeting their care needs and did not express any concerns with privacy or dignity. Residents’ interviews indicated that staff were treating all residents with dignity and respect and did not express any issues. Resident’s interviews indicated their satisfaction with staff’s professionalism and did not express any issue with staff were being rough with their care or speaking to them in any inappropriate manner. Staff interviews reflected that staff were treating all residents with respect and dignity and were not speaking inappropriately to any residents. Based on facility tour, interviews and observation, the department found this allegation is to be UNFOUNDED. Based on the investigation, the preponderance of evidence standards has not been met. Therefore, the above all allegations is found to be UNFOUNDED. A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit meeting conducted. A copy of this report has been provided to facility. **report continued from 9099-A...... Allegation- Staff do not provide adequate care and supervision to resident in care.-Unsubstantiated The Department conducted interviews with staff and residents and reviewed records to investigate the allegation. Department conducted interviews with Administrator, Five (5) residents and four (4) staff to investigate this allegation. During the interview process it was reported that staff supervise residents twenty-four (24) hours a day and check on residents every two hours to provide residents toilet care needs. It was reported that staff are conscience of keeping the residents clean and dry. Resident’s interviews reflected that staff were providing care per their needs and service plan and there were no issues. LPA toured the facility and facility observed to be clean sanitary and free from odors. LPA did not observe any dirty diapers or smell of urine/feces. Record review reflected that facility has adequate staffing to meet all resident’s needs. It was also noted that facility staff were providing care to residents per their needs and service plan without any issues and keeping documentation records as needed. Staff interviews reflected that they were aware about residents’ care needs as indicated in their Needs And Service Plans and assisting residents accordingly without any issues. Based on this information, this allegation is Unsubstantiated. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted. Copy of the report provided.the state’s words, verbatim · CDSS document, Nov 7, 2024 · control 59-AS-20241014174428

Allegation investigated: Sewer system is down/backed-up in the kitchen. Facility is not following pet policy for residents. Laundry room is not clean and exposed electric wires throughout the facility which pose safety concern.

On 07/31/24, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced and met with Administrator, Danielle Shanklin to deliver complaint findings into allegations listed above. LPA explained the purpose of the visit upon arrival. The department conducted records review ,facility observations and interviews to investigate the complaint. **Report continued on LIC9099-C** Unfounded ***Report continued from 9099..... Allegation- Sewer system is down/backed-up in the kitchen. --UNFOUNDED The Department conducted facility’s observations, record review and interviewed four (4) residents and five (5) staff members to investigate the complaint allegation. Staff interviews indicated that facility’s kitchen had leak in one of the drainpipes which was reported to the Department on 06/24/24. Facility contacted plumbing company who came in on 06/26/24 and fixed the leak. It was also learned that kitchen’s ‘water booster’ machine which is used for cleaning and sanitizing dishware was broken around 07/05/24 and work order was placed on 07/06/24. At this time, facility was waiting for the delivery of the part, and it will be installed by Eco Lab once delivered. Due to this issue, facility was using disposable dishware for residents meals service but meals services were not affected. Facility sewer system was found to be working fine without any issues. Based on all this information, this allegation was found to be UNFOUNDED. Allegation- Facility is not following pet policy for residents. -UNFOUNDED The Department conducted facility’s observations, record review and interviewed four (4) residents and five (5) staff members to investigate the complaint allegation. During facility’s tour on 07/18/24, facility was found to be clean and odor free. Record review indicated that per residents’ admission agreement, residents were responsible to take care of their pets and residents were following that policy without any issues. Four (4) residents interviews conducted on 07/18/24 indicated that they were not aware about any issues that facility was not following pet policy. Residents did not report any dog urine or feces at the facility. Five (5) staff interviews conducted on 07/18/24 indicated that there were no issues with any residents’ pets at facility. Staff interview reflected that if residents require any assistance with their pet’s care, they can ask help from staff and staff help them without any problems. Based on this information, this allegation was found to be UNFOUNDED. **Report continued on LIC9099-C** ***Report continued from 9099...... Allegation- Laundry room is not clean and exposed electric wires throughout the facility which pose safety concern. -UNFOUNDED The Department conducted facility’s observations, record review and interviewed four (4) residents and five (5) staff members to investigate the complaint allegation. During Department visit on 07/18/24, facility ‘s laundry rooms were observed to be clean and organized. Additionally, there were no open electric cords noted at the facility which can be safety concern for residents. Four (4) residents interviews conducted on 07/18/24 indicated that facility has clean Landry room for resident’s use and there were no issues. Resident’s interviews indicated that they did not see any open electric cords at facility. Five (5) staff interviews conducted on 07/18/24 indicated that facility provide clean and sanitary laundry area and there were no problems. Staff interviews reflected that there were no open electric cords at facility which can be safety concern for anyone. Based on this information, this allegation was found to be UNFOUNDED. Based on the investigation, the preponderance of evidence standards has not been met. Therefore, the above all allegations is found to be UNFOUNDED. A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit meeting conducted. A copy of this report has been provided to facility.the state’s words, verbatim · CDSS document, Jul 31, 2024 · control 59-AS-20240717092636

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 06/20/24 to conduct a case management to follow up on a recent AWOL at the facility for resident, R1. LPA met with facility Administrator , Danielle Shanklin and explained the purpose of the visit. The facility submitted a completed Unusual Incident/Injury Report (LIC624) on/around 06/04/24 regarding resident (R1) leaving the facility unattended on 06/03/24, at approximately 6:30 pm. IR stated that R1 got lost while on walk outside the facility after having dinner with their family member around 06:30pm. IR indicated that R1 was found lost on close by street by facility by bystander who notified law enforcement around 07:20pm and R1 was brought back by them uninjured to the facility. R1's physician's report, dated 02/17/24, indicates that resident has diagnosis of dementia (primary) and cannot leave the facility unassisted. This was first AWOL incident for R1 since admission to the facility. R1 has been discharged to another facility for higher level of care. Although no injuries resulted from R1’s AWOL, R1 was unable to leave the facility unassisted. Facility staff did not provide care and supervision to R1 resulting in R1 leaving the facility unassisted therefore violations are cited today per California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies issued are noted on the LIC809D. Exit interview conducted. Copy of report and appeal rights provided to administrator.the state’s words, verbatim · CDSS document, Jun 20, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(4) · Plan of correction due date: Jun 21, 2024

87705- Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by: Based on interviews conducted and record review, facility staff did not provide care and supervision to R1 resulting in R1 leaving the facility unassisted on 06/03/24 which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 20, 2024

Plan of correction: Current Licensee/Administrator will conduct staff training on keeping a closer watch on any residents that may have a tendency for wondering behaviour and document any changes in condition. Documentation of training shall be provided to Department by POC date-06/21/24.

Type of visit: Prelicensing

On 03/04/24, Licensing Program Analyst (LPA) Talwinder Bains met with administrator Danielle Shanklin, to conduct an Pre- Licensing visit. This application is a change in ownership (CHOW) . This address is currently licensed as ,BLOSSOM VALE SENIOR LIVING, Facility # 342700257. Administrator holds a current administrator certificate (# 6057022740 with expiration date 07/24/2025). The facility currently has 92 residents during today's inspection. Facility has Fire Clearance for 120 residents of which 108 can be non-ambulatory and 12 can be bedridden( rooms 101-157 only) from date Fire Inspection date- 02/07/24. LPA toured the facility with administrator. LPA toured 2 sample residents bedrooms and they were properly furnished and maintained. LPA toured common bathrooms and observed to be clean and sanitary. The food supply is within compliance, 2 days of perishable and 7 days’ worth of non-perishable food items. Smoke detectors are operational. There are carbon monoxide detectors which are functioning. The Fire extinguisher was charged, serviced and functional. Grab bars were present at the toilet and in the shower. All exits were unobstructed. All toxins, medications, and sharps were locked and stored away. The disaster drill is current. Component III was waived as the current administrator has been administrator for other RCFE licensed by CCLD . LPA will forward findings to the Centralized Application Bureau (CAB) that facility met all the pre-licensing components. Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations on today's pre-licensing inspection. A copy of this report was provided to the facility. Exit interview conducted.the state’s words, verbatim · CDSS document, Mar 4, 2024

Type of visit: Office

Facility Type: Residential Care Facility for the Elderly Application Type: Change of Ownership COMP II Participants: Danielle Shanklin Interview Method: Telephone interview On December 04, 2023, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restricted/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Dec 4, 2023