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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002619
Report Date: 04/23/2021
Date Signed: 04/23/2021 10:33:01 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 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/27/2020 and conducted by Evaluator Misty Valencia
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20201027111648
FACILITY NAME:ROSELEAF OROVILLEFACILITY NUMBER:
045002619
ADMINISTRATOR:BROWN, TERRYFACILITY TYPE:
740
ADDRESS:1900 20TH STREETTELEPHONE:
(530) 538-8200
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY:0CENSUS: DATE:
04/23/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Terry Brown, AdministratorTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Facility staff failed to supervise resident which resulted multiple falls
Facility did not observe change in condition
Facility did not provide a safe environment to resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced complaint investigation and met with Administrator Terry Brown. LPA Valencia explained the reason for the visit was to deliver the investigation findings for the above allegations.


Continued on 9099C

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021
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 6
Control Number 25-AS-20201027111648
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 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: ROSELEAF OROVILLE
FACILITY NUMBER: 045002619
VISIT DATE: 04/23/2021
NARRATIVE
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Neglect/lack of care and supervision: staff failed to supervise resident (R1) which resulted in R1 falling multiple times and sustaining bruising and injuries, facility did not observe change in condition, facility did not provide a safe environment to resident-Unsubstantiated.
The Department interviewed facility staff, residents, and record reviews. During the investigation, it was determined that there was insufficient evidence to substantiate neglect/lack of care and supervision, facility did not protect personal rights of residents, facility did not observe change in condition, and facility did not provide a safe environment to resident. (evidence- records review and interviews) found that staff sent R1 to the emergency room after each occurrence. Primary Care Physician Dr, Cole said R1 has “advanced dementia” and R1’s skin is frail and will tear and bruise easily. R1 has been getting worse for the last two-three years. Dr Cole last examined R1 one month before moving into the facility. According to Oroville Hospital medical records, R1 was seen on three visits for slip and fall injuries. On 10-25-2020, R1 medical records did not mention any bruising on R1. On 10/26/2020, medical records indicated R1 has “multiple bruises and lacerations.” Registered Nurse (RN1) RN1 stated that when they examined R1 on 10/26/2020, they observed several fresh and old bruises in R1’s shoulders, upper right arm and both knees. Staff 1 (S1) stated that when they saw R1 on 10/25/2020 at 2000hrs R1 did not have any bruises. Staff 2 (S2) stated that was with Staff 3 (S3) on 10/26/2020, when they heard a “boom sound” and when they looked, they saw R1 laying on the floor by her wheelchair alone. Husband 1 (H1) said that when he visited R1 in October 2020, they appeared “doped up.” The third fall on 10/26/2020, was witnessed by Staff 4 (S4). R4 said that they was about 15 feet away sitting at a table when they saw R1 try to get out of her wheelchair and they fell forward onto the ground striking their head and arms on the floor. S4 stated that it happened so fast they was not able to get R1 in time to stop the fall. Although R1 had three falls in October 2020, the staff either had R1 checked by a med tech or contacted medical personnel in a timely manner.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 25-AS-20201027111648
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 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: ROSELEAF OROVILLE
FACILITY NUMBER: 045002619
VISIT DATE: 04/23/2021
NARRATIVE
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Facility contacted family and local hospital regarding all incidents and any change in conditions. R1 was using a wheelchair while at the facility and their primary care physician’s report did not list them as using a wheelchair. R1’s appraisal/needs and Services plan did not list a wheelchair neither. Staff and witnesses who were interviewed did not corroborate the allegations, therefore the department has found the allegations to be unsubstantiated.

The preponderance of evidence standard has not been met. The allegation is Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/27/2020 and conducted by Evaluator Misty Valencia
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20201027111648

FACILITY NAME:ROSELEAF OROVILLEFACILITY NUMBER:
045002619
ADMINISTRATOR:BROWN, TERRYFACILITY TYPE:
740
ADDRESS:1900 20TH STREETTELEPHONE:
(530) 538-8200
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY:CENSUS: DATE:
04/23/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Terry Brown, AdministratorTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Facility did not provide incontinence care
Facility did not protect personal rights of residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced complaint investigation and met with Administrator Terry Brown. LPA Valencia explained the reason for the visit was to deliver the investigation findings for the above allegations.

Continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 25-AS-20201027111648
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 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: ROSELEAF OROVILLE
FACILITY NUMBER: 045002619
VISIT DATE: 04/23/2021
NARRATIVE
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Neglect/lack of care and supervision: Facility did not protect personal rights of residents, and staff neglected R1 by failing to change their soiled diaper for at least 2 days -Substantiated.

The Department interviewed facility staff, residents, and record reviews. During the investigation, it was determined that there is sufficient evidence to substantiate neglect/Lack of care and supervision, and facility did not protect personal rights of residents. On 10/26/2020, While R1 was being examined by Oroville Hospital RN1 for a slip and fall injury, RN1 noticed the diaper that R1 was wearing was dated 10/20/2020. RN1 took photographs of the soiled diaper. S2 and Staff 5 (S5) both admitted to “forgetting” to change R1’s diaper. S2 and S5 also gave written confession admitting to forgetting to change R1’s diaper. The Department finds that the facility is failing to attend to client's personal hygiene needs and incontinence care, which violates client's personal rights.
Based on the findings of this investigation LPA finds allegations to be SUBSTANTIATED - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 rules and regulations, Health and Safety Codes, and Welfare and Institutions Code.

An exit interview was conducted and a copy of this report, dated April 23, 2021 was provided
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 25-AS-20201027111648
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 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ROSELEAF OROVILLE
FACILITY NUMBER: 045002619
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/30/2021
Section Cited
CCR
87468.1(a)(2)
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Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations... This requirement is not met as evidenced by:
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Administrator agrees to conduct staff training dealing with resident’s rights for recognizing and reporting abuse/neglect on all shifts by 4/28/2021 date.
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Based on staff interviews, the licensee failed to ensure that residents were afforded their personal rights at all times and checked on when needed, which poses an immediate health and safety risk to residents in care.
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A signed list of attendees shall be submitted to CCL with the topics discussed as well
Type A
04/30/2021
Section Cited
CCR
87625(b)(2)
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Managed Incontinence, General Requirements for Allowable Health Conditions...Ensuring that incontinent residents are checked..when they are known to be incontinent.... This requirement is not met as evidenced by:
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Administrator agrees to provide a staff training to all staff relative to the care needs managed Incontinence care, by 4/28/2021 date.
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Based on interviews and record review the licensee failed to ensure that 1 of 1 clients were not was left in a clean diaper, R1 was left in a soiled diaper for hours prior to being changed by caregiver which poses an immediate health and safety risk to residents in care
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A signed list of attendees shall be submitted to CCL with the topics discussed as well
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 BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6