045002619-10-19-2020-25-AS-RLBN-BULSMX-20201021140039

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045002619
Report Date: 10/12/2020
Date Signed: 10/19/2020 09:13:15 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:	10/12/2020
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	TERRY BROWN		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not notify resident’s authorized representative of an injury in a timely manner; and Facility staff provided inaccurate information to resident’s authorized representative.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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 Facility staff did not notify resident’s authorized representative of an injury in a timely manner; and Facility staff provided inaccurate information to the resident’s authorized representative.

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

**continued**

Unsubstantiated

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: 10/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2020

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 2

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: 10/12/2020

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
26
27
28
29
30
31
32

**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 taken to UC Davis Burn Center, Sacramento, California.

The administrator, staff persons, the resident and the authorized representative were interviewed. Staff persons reported that the resident’s authorized representative was contacted; however, it could not be determined how quickly or timely the representative was notified of the incident. In addition, it could not be confirmed what information was provided to the resident’s authorized representative that was inaccurate.

Based on the information obtained and interviews conducted, the above allegation is Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are Unsubstantiated.

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 2