Blossom Valley Care Home

Allegation investigated: Facility did not meet resident's hygiene needs. Staff allowed resident to be left in soiled clothing for extended periods of time.

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 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.the state’s words, verbatim · CDSS document, Apr 3, 2026 · control 26-AS-20260327105535

Type of visit: POC

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced Plan of Correction (POC) visit and met with Licensee/ADM Ronnie Ubungen During POC visit, LPA verified the water temperature and secure medications based on the written plan of action that facility has provided to CCLD on 12/23/2025. LPA advised ADM to continue to monitor water temperature and monitor staff that they are securing medications after passing and administering prescription medication to residents. POC reviewed and cleared the Type A deficiency cited on 12/23/2025 under California Code of Regulation (CCR) Title 22 87303(e)(2) and 87465(h)(2) on site and provided a copy of POC Clearance Letter to administrator Ronnie Ubungen. No deficiency cited during today's inspection. Exit interview conducted with administrator Ronnie Ubungen and a copy of the report was provided. end of reportthe state’s words, verbatim · CDSS document, Jan 6, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced Required 1 Year visit and met with Administrator (ADM) Ronnie Ubungen and Licensee (LIC) Maybelline Ubungen. LPA stated the purpose of the visit. The facility serves age 60 and over. Five may be non-ambulatory. One may be bedridden. Bedroom #3 and #4 are approved for one bedridden client and hospice waiver for two. LPA observed 6 resident and 3 staff at the time of the inspection. LPA toured the facility including but not limited to the kitchen, dining, activity room, 3 resident room all shared. 1 staff room, garage, bathroom and exterior perimeter. The exterior perimeter and walkway are free from obstruction/debris. The ramp and back deck are maintained, handrails and ramp is sturdy. LPA observed a gazebo in the backyard. Fence was propped up a bougainvillea plant from the neighbor was hanging over the fence, a frayed window screen was observed from the exterior side by the dining area. LPA inspected the kitchen and observed food supply for at least 2 days of perishable food and 7 days of non-perishable food. Sharps and medications were locked in secured areas. Cleaning and laundry supplies are in a separate storage and locked. Resident's bedroom have sufficient storage to store personal items. The bathroom is equipped with grab bars and non-skid floors for adults who are non-ambulatory and ambulatory residents. 1 Out of the 2 bathroom is equipped with a toilet seat riser, and bath bench/chair. page 1 of 2 While inspecting the kitchen drawers LPA observed 4 medications that were not locked and accessible to residents in care. Staff locked the 4 medications expeditiously. The water temperature in 2 bathrooms when measured with a digital thermometer is at 140.9 to 143.7 degree F. The kitchen water sink measured at 145 degree F. The facility room temperature is at 72 degree F. Refrigerator temperature is at 40 degree F and freezer is at 0 degree F. The facility is equipped with a fire alarm system that is in good working condition a fire extinguisher inspected on 05/08/2025. Emergency disaster preparedness was done on 08/5/2025. Fire drill was done on 1/18/25, 4/21/25, 7/17/25 and 10/24/25. A first aid kit complete with the guidebook. LPA gave technical assistance for the earthquake drill resources. LPA Partoza reviewed facility record, 3 staff and 3 residents records such as but not limited to medical assessment (LIC 602A), centrally stored medication and destruction record (CSMDR), appraisal needs and services plan, personal rights, and consent forms. LPA reviewed staff record such as but not limited to training, criminal background clearance, mandated reporting (SOC 341A) and health screening. Deficiencies were cited during today's visit based on California Code of Regulations (CCR) Title 22 87303 (e)(2) and 87465(h)(2) See LIC 809D. An exit interview was conducted with Administrator (ADM) Ronnie Ubungen and Licensee (LIC) Maybelline Ubungen a copy of the report and appeals rights were provided page 2 of 2 end of reportthe state’s words, verbatim · CDSS document, Dec 23, 2025

Allegation investigated: Facility staff neglected to care for the resident's wounds.

Licensing Program Analyst (LPA) conducted an unannounced investigation visit and met with Administrator Ronnie Ubungen (ADM). On 12/18/2024, the Department received a complaint with the allegation that facility staff neglect to care for resident R1's wounds. LPA toured the facility with ADM. LPA requested the resident roster and LIC 500. LPA observed 5 residents and 4 staff in the facility. Continue on LIC9099-C. page 1 of 2. Unfounded The allegation is that the facility staff did not take care of resident R1's wound resulting in R1 being sent to hospital. LPA interviewed Administrator (ADM) Ronnie Ubungen. ADM stated the facility does not have R1 as resident and did not admit R1 before. LAP interviewed house manager Maybelline Ubungen (HM). HM stated the facility never has R1 as resident. HM stated there is a health institute with the similar same Blossom Valley Care Health center around the facility, and there were some similar confusion/mistake occurred before. LPA interviewed 3 staff. 3 Out of 3 staff stated the facility does not have R1 as resident. LPA interviewed 5 residents. 5 Out of 5 residents stated R1 is not a resident in the facility. LPA reviewed resident roster, LPA did not find R1 in the resident roster. The facility's capacity is 6. LPA observed 5 residents and one empty bed, and did not see any other resident in the facility. Based on the observation, interview, and records reviewed, R1 is not a resident of the facility. The Department has investigated the above allegation. Based on the investigation, observation, documents reviewed, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. No citations noted at today’s compliant investigation visit. The exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM.the state’s words, verbatim · CDSS document, Dec 23, 2024 · control 26-AS-20241218141227

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with administrator (ADM) Ronnie Ubungen. LPA observed 5 residents and 2 staff at facility. LPA reviewed 3 resident files and 3 staff files. 2 Out of 3 resident files were observed that centrally stored medication forms were not matched with their medications. Facility license, Administrator Certificate, and personal right posters were observed at main entrance. LPA toured the facility with ADM inside and out. LPA inspected living room, family room, dinning area, kitchen. There are 2 restrooms, 1 staff live-in room, 3 resident rooms in facility. Grab bars and non slipping resisted floor were observed at the restrooms. Two days perishable foods and seven days non perishable foods were observed sufficient. Room temperature was observed at 68 degree F, hot water temperature was observed at 119 degree F. Temperature of refrigerator was measured at 45 degree F, and temperature of freezer was observed at 0 degree F. Medication cabinet, Knives closet and cleaning products closet were observed locked. Fire extinguisher was serviced on 5/21/2024. The facility is equipped with fire alarm and carbon monoxide detectors. Smoke detector alarm system was tested, and was working fine. First Aide Box, night lights and emergency flash lights were observed. Front yard and backyard were inspected. There was no obstruction to block the walkways. Facility last fire and emergency drill was conducted on 10/20/2024. Citation was issued today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was provided to ADM.the state’s words, verbatim · CDSS document, Dec 6, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection, and met with administrator (ADM) Ronnie Ubungen. LPA observed 6 residents and 3 staff at facility. LPA reviewed 5 resident files and 3 staff files. Facility license, Administrator Certificate, and personal right posters were observed at main entrance. LPA toured the facility with ADM inside and out. LPA inspected living room, family room, dinning area, kitchen. There are 2 restrooms, 1 staff live-in room, 3 resident rooms in facility. All the trash cans were observed with covers. Grab bars and non skid floor were observed at the restrooms. Two days perishable foods and seven days non perishable foods were observed sufficient. Room temperature was observed at 71 degree F, hot water temperature was observed at 118 degree F. Temperature of refrigerator was measured at 40 degree F, and temperature of freezer was observed at 0 degree F. Medication cabinet, Knives closet and cleaning products closet were observed locked. Fire extinguisher was serviced on 4/17/2023. The facility is equipped with fire alarm and carbon monoxide detectors. Smoke detector alarm system was tested, and was working fine. First Aide Box, night lights and emergency flash lights were observed. Front yard and backyard were inspected. There was no obstruction to block the walkways. Facility last fire and emergency drill was conducted on 10/20/2023. No citation was issued today. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was provided to ADM.the state’s words, verbatim · CDSS document, Dec 8, 2023