045002445-3-24-2023-25-AS-KMKY-CMANDY-20221220092306

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 045002445
Report Date: 12/20/2022
Date Signed: 03/24/2023 11:01:18 AM

Document Has Been Signed on 03/24/2023 11:01 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/24/2023 10:38 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Please note, your appeal regarding the assessment of the civil penalties has already been received on 2/9/2023 dated 2/9/2023 and will be included in the Administrative Action on this matter. The Department is updating this 809 report to reflect that the previously issued report dated 12/20/2022 is amended to reflect that the Enhanced Civil Penalty (ECP) assessed at this visit is assessed solely as against FDM and does not include Peer Services, Inc. Peer Services, Inc. did not begin their association with the facility until October 8, 2020 and the incident referred to in this report happened before their legal obligations to the facility was in effect. This facility is closed, therefore this report, LIC 421D and appeal rights are being sent to the licensee by certified mail. This report is for a Case Management visit to follow up on two substantiated allegations, including resident (R1) eloping from the facility for 2 or more hours as well as R1 sustaining blisters to their feet and suffering heat exhaustion due to elopement, both issued to the facility on April 22, 2021 for investigation control number 25-AS-20200819115459. On April 22, 2021, the Department concluded a complaint investigation received on August 19, 2020, which alleged that R1 eloped and was outside of the facility in the garden area for more than two hours, and R1 sustained blisters to their feet and suffered heat exhaustion due to the staff’s lack of care and supervision. During the investigation, interviews were conducted, and documentation was obtained that is pertinent to the investigation. R1’s Physician’s Report (LIC602) dated for August 6, 2020, states that R1 has a primary diagnosis of dementia, may be confused/disoriented, and has wandering behaviors. Incident Report dated August 15, 2020 stated that, since August 14, 2020, facility managers have conducted team meetings to review Extreme Heat Preparedness Procedures in anticipation of the changing weather over the weekend. Continued...

SUPERVISOR'S NAME: Alycia Berryman	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Lauren Crocker	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ROSELEAF GARDENS	FACILITY NUMBER: 045002445
	VISIT DATE: 12/20/2022

NARRATIVE

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Prior to this incident, R1 did not have any of the above documented medical conditions.

According to the Weather Channel, the local temperature at the facility’s city was sunny and 109 degrees Fahrenheit.

Deficiencies were cited for violating California Code of Regulations, Title 22 Division 6, Chapter 8, Section 87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

At the time of the complaint visit on April 22, 2021, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty was still being determined and might be assessed based on Health and Safety Code § 1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Per Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of or protracted loss or impairment of function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation.”

Today, (DATE to be Determined), the Department will be issuing a civil penalty per Health and Safety Code § 1569.49, for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was issued on April 22, 2021, the amount of the civil penalty today will be $9,500. A copy of this report and LIC 421D are certified mailed to the licensee with request to return signed copies .

SUPERVISOR'S NAME: Alycia Berryman	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Lauren Crocker	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ROSELEAF GARDENS	FACILITY NUMBER: 045002445
	VISIT DATE: 12/20/2022

NARRATIVE

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Perimeter checks were increased to every hour on rotation to closely monitor the secured outdoor areas. Despite increased monitoring of secured outdoor areas at the facility, R1 was outside long enough to sustain injuries on August 15, 2020.

Staff (S1) stated that, on August 15, 2020, they last saw R1 in the facility dining room at approximately 1:00 p.m. before going on break. Staff (S2) stated that it was very hot on August 15, 2020, and that they could only handle being outside for five minutes. S2 stated that they saw R1 outside multiple times that day but could not recall for how long. S2 was not aware that R1 had been missing upon finding the resident outside. S2 had taken an outside shortcut through the courtyard from one building to another when they found R1 standing in some bushes while barefoot outside at approximately 2:15 p.m. The facility’s video system did not show the courtyard where R1 was found barefoot. S2 stated R1 looked panicked and confused. S2 sat R1 at a bench and contacted S3. S3 provided some cold water to R1 and S2 went back to their post. S3 described that R1 was observed with a bright red face, very sweaty, looked very confused and their skin was hot to the touch. S3 contacted 9-1-1, and then asked for a wheelchair to take R1 into the air-conditioned lobby. S3 stated R1’s body temperature was 99 degrees Fahrenheit. Cold towels were placed on R1's head and neck. R1’s feet were significantly blistered. The outside temperature was about 115 degrees Fahrenheit and the ground was very hot. The ambulance arrived about 10 minutes after S3 called 9-1-1. The local hospital doctor (D1) stated that, based on R1’s medical exam: R1 arrived at the Emergency Room (ER) with a temperature of 101.4 degrees Fahrenheit at 3:24 p.m. on August 15, 2020. D1 determined that R1 had to be outside for roughly 2 hours before being found. The timeline provided by the facility staff does not seem to be accurate based on D1’s assessment of R1 upon arrival in the ER.

According to R1’s medical records from the ER visit on August 15, 2020, R1 was diagnosed with dehydration, dementia, heat stroke, sunstroke, partial thickness burns on both feet with second degree burns on the left foot, and a mild acute kidney injury with hyperkalemia (per mayoclinic.org, hyperkalemia is a higher than normal potassium level in the blood). R1’s final diagnosis included hyposthenia associated with heat, acute kidney injury, and blisters with epidermal loss due to second degree burns on R1’s foot. Continued...

SUPERVISOR'S NAME: Alycia Berryman	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Lauren Crocker	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC809 (FAS) - (06/04)

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