Blossom Residential II

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

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 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.the state’s words, verbatim · CDSS document, Oct 27, 2025 · control 59-AS-20251008085349

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Oct 28, 2025

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: 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.the state’s words, verbatim · CDSS document, Oct 27, 2025

Plan of correction: 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.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on October 15, 2025 to conduct a Required-1 Year Inspection utilizing the inspection tool. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are four (4) bedrooms and three (3) bathrooms for resident use and one (1) bedroom for staff. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 109 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required two (2) day perishable and seven (7) day non-perishable food supply on cite. LPA observed knives, cleaning products, and other toxins to be locked away and inaccessible to residents. LPA observed the backyard and perimeter of the care home to be free of clutter and debris. LPA observed smoke detectors and carbon monoxide detectors to be operational in the care home. First aid kit is maintained and ready for emergency use. LPA reviewed two (2) residents' medications and observed medication storage to be locked away and inaccessible to the residents. LPA reviewed four (4) resident files and three (3) staff files. Facility has a current copy of certificate of liability insurance and LPA obtained a copy. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit was interview conducted and copy of report given at the conclusion of this visit.the state’s words, verbatim · CDSS document, Oct 15, 2025

Allegation investigated: Facility staff are not treating residents with dignity Unlawful eviction notice was issued to resident

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 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 ** 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.the state’s words, verbatim · CDSS document, Apr 9, 2025 · control 59-AS-20250401143759

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Apr 10, 2025

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: 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.the state’s words, verbatim · CDSS document, Apr 9, 2025

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.683 · Plan of correction due date: Apr 24, 2025

§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: 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.the state’s words, verbatim · CDSS document, Apr 9, 2025

Plan of correction: Facility will complete a statement of understanding regarding regulation §1569.683 and submit statement to LPA by POC due date.

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Michael Hood arrived at the care home unannounced on 4/3/25 to conduct a post licensing visit. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are four (4) bedrooms and three (3) bathrooms for resident use and one (1) bedroom for staff. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 105.6 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required two (2) day perishable and seven (7) day non-perishable food supply on cite. LPA observed knives, cleaning products, and other toxins to be locked away and inaccessible to residents. LPA observed the backyard and perimeter of the care home to be free of clutter and debris. LPA observed smoke detectors and carbon monoxide detectors to be operational in the care home. First aid kit is maintained and ready for emergency use. LPA reviewed two (2) residents' medications and observed medication storage to be locked away and inaccessible to the residents. LPA reviewed six (6) resident files and two (2) staff files. Facility has a current copy of certificate of liability insurance and LPA requested a copy. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit was interview conducted and copy of report given at the conclusion of this visit.the state’s words, verbatim · CDSS document, Apr 3, 2025

Type of visit: Prelicensing

Licensing Program Analysts (LPAs) Cassandra Mikkelson and Michael Hood met with Administrator, Raluca Solovyev, to conduct a Pre- Licensing visit. The facility has a fire clearance for six (6) non-ambulatory residents. Administrator Raluca Solovyev has an active certificate (#7022001740 with expiration date 03/09/2026). LPAs conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are four (4) bedrooms and three (3) bathrooms for resident use and one (1) staff room. Bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 117.5 degrees F. LPAs observed facility has the ability to prepare and store food, to lock away cleaning products and other toxins, and lock medications to make inaccessible to residents. LPAs observed smoke detectors and carbon monoxide detectors at the care home to be operational. Component III was waived. Application is pending and LPAs will forward findings to the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application. A copy of this report was provided to the facility. Exit interview conducted.the state’s words, verbatim · CDSS document, Dec 4, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 Interview Method: Telephone interview On 11/13/2024, applicant/administrator participated in COMP II. Identification of the applicant / administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant / administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. 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. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Nov 13, 2024