045002619-10-12-2020-25-AS-RLBN-BULSMY-20201021140039

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045002619
Report Date: 10/09/2020
Date Signed: 10/12/2020 09:49:05 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/29/2020 and conducted by Evaluator Donna Gurriere

COMPLAINT CONTROL NUMBER: 25-AS-20200729095832

FACILITY NAME:	ROSELEAF OROVILLE		FACILITY NUMBER:	045002619
ADMINISTRATOR:	BROWN, TERRY		FACILITY TYPE:	740
ADDRESS:	1900 20TH STREET		TELEPHONE:	(530) 538-8200
CITY:	OROVILLE	STATE: CA	ZIP CODE:	95965
CAPACITY:	60	CENSUS: 39	DATE:	10/09/2020
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	TERRY BROWN		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Lack of supervision resulting in a resident sustaining burns; and
Facility staff did not follow the resident’s care plan.

INVESTIGATION FINDINGS:

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Donna Gurriere, Licensing Program Analyst (LPA) was in contact with Terry Brown, Administrator. A physical visit could not be made due to the orders in place regarding the Corona Virus. It was alleged that there was A lack of supervision resulting in a resident sustaining burns and that the Facility staff did not follow the resident’s care plan.

The administrator, staff persons, resident and the resident’s authorized representative were interviewed. In addition, numerous records were obtained and reviewed from the resident’s previous facility, a Residential Care Facility for the Elderly (RCFE) and from where the resident is currently recovering at an acute care facility.

**continued**

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2020

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 4

Control Number 25-AS-20200729095832

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: ROSELEAF OROVILLE	FACILITY NUMBER: 045002619
	VISIT DATE: 10/09/2020

NARRATIVE

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**continued**

On 04/25/20 a resident was at the facility when he sustained serious burns to his left leg due to a cigarette smoking incident. The resident’s facility care plan states “Fall risk, resident is a smoker, must be with staff while smoking. Refused to wear protective apron.” It was reported that the resident had just finished lunch and wanted to have a cigarette. The resident was given a cigarette and a lighter from a staff person and was advised to wait for the staff person to be available to accompany him on his cigarette break. Unnoticed, the resident in his wheelchair took himself outside and had a cigarette without a staff person present. Staff reported that the resident was seen entering the facility with burn marks on his pants and leg. Emergency services were contacted, and the resident was taken to the local hospital. It was later reported that due to the severity of the burns, the resident was transported to UC Davis Burn Center, Sacramento, California.

On 05/18/20, the resident was admitted to an acute care center. Admittance records stated “Admitted to this facility on 05/18/2020 after hospitalization. Hospital course: Admitted for left lower extremity burns – clothing was set on fire while smoking a cigarette, underwent skin grafting of left lower extremity, anemia of blood loss, A1c5.9.”

On 06/01/20, the physician’s notes state “Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue. Burn of third degree of left lower leg, sequela.”

On 09/21/20, Physician/NP/PA Progress notes state the resident had a physical exam and the resident’s general appearance is “Alert. Comfortable.” Resident is currently residing at the acute care center.

**continued**

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 25-AS-20200729095832

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: ROSELEAF OROVILLE	FACILITY NUMBER: 045002619
	VISIT DATE: 10/09/2020

NARRATIVE

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**continued**

A staff person gave the resident a cigarette and lighter. Had the staff person not given the resident his cigarette and lighter, the resident would have had to wait for staff to accompany him to have a cigarette, as per his care plan. There was a lack of supervision, which resulted in the resident sustaining serious burns to his left leg and the facility did not follow the resident’s care plan. Allegations are substantiated.

Based on the evidence obtained, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be Substantiated. California Code of Regulations, Title 22, is being cited on the attached LIC 9099D. Appeal rights provided.

The facility is being advised that under H&S Code §1568.0822(f) the issuance of an Enhanced Civil Penalty (ECP) is currently under review and may be assessed later, due to a resident sustaining serious bodily injury while in care of the facility.

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 25-AS-20200729095832

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: ROSELEAF OROVILLE	FACILITY NUMBER: 045002619
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/09/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/07/2020 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	Basic services shall at a minimum include: 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:	1 2 3 4 5 6 7	The administrator agrees to develop and provide a policy to the licensing agency that advises how this type of deficiency will be avoided in the future. Plan of correction for a Type A shall be submitted within 24 hours.
	8 9 10 11 12 13 14	Based on investigation findings, records obtained and reviewed, and statements received. The facility did not provide care and supervision to a resident when the resident was admitted for left lower extremity burns as his clothing was set on fire while smoking a cigarette. Resident underwent skin grafting of left lower extremity and was placed in an acute care center.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2020

LIC9099 (FAS) - (06/04)

Page: 4 of 4