045002619-3-24-2023-25-AS-MVAA-C5LUZB-20210805160114

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 045002619
Report Date: 08/05/2021
Date Signed: 03/24/2023 11:23:19 AM

Document Has Been Signed on 03/24/2023 11:23 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/24/2023 10:02 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 8/23/2021 dated 8/19/2021 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 8/5/2021 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, as they did not begin their association with the facility until October 8, 2020 and the incident referred to in this report happened on April 8, 2020, before their legal obligations to the facility were in effect. On 07/23/2021, Licensing Program Analyst (LPA) Misty Valencia, met with the Previous Licensee's Florie and David Kupermam, of Roseleaf Oroville for a case management visit to follow up on a substantiated allegation of neglect/lack of supervision. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted facility and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. Additionally, LPA was screened by care staff. On October 9, 2020, the Department concluded a complaint investigation which alleged that a lack of care and supervision resulted in a resident catching clothing on fire while smoking and was burned. It was alleged that R1 had exited the facility unaccompanied into a patio area commonly used for smoking, lit a cigarette, and R1’s left pant leg was ignited and caught fire resulting in a burn to R1’s leg. continued on 809-C

SUPERVISOR'S NAME: Alycia Berryman	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Lauren Crocker	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

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 OROVILLE	FACILITY NUMBER: 045002619
	VISIT DATE: 08/05/2021

NARRATIVE

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Two complaint allegations, lack of supervision resulting in a resident sustaining burns, and facility staff not following a resident’s care plan, were substantiated and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87464(f)(1) for failure to provide a resident with basic services to include care and supervision. Specifically, on April 25, 2020, the facility failed to provide appropriate supervision to R1 while smoking which resulted in R1 catching an article of clothing on fire and experiencing burns to the left leg.

The investigation revealed that and that R1 made a request from staff to go outside to smoke and was asked to wait, as no staff were available due to lunch clean up duties.

During the investigation, staff interviews revealed that on April 25, 2020 around
12:50 p.m., R1 asked staff S1 to accompany R1 outside to smoke a cigarette. Interviews and documents gathered during the course of the investigation show that R1 had a history of smoking around this time of day. R1 had a Physician’s Report on file dated October 10, 2019 that specifically stated R1 requires supervision while smoking. Staff #1 (S1) told R1 to wait since all staff were occupied cleaning the dining room following lunch. R1 was provided a cigarette and a lighter and R1 proceeded to the smoking area without a staff present. In interview, staff stated that R1 regularly would go out to the patio alone but there was no expectation that R1 would try to light the cigarette and smoke without supervision. It remains unknown who provided R1 with a cigarette and a lighter, as no staff admitted to providing these items and no staff admitted knowledge of who may have provided them. R1 was interviewed by an LPA, however the LPA did not ask R1 who provided the cigarette or lighter. Around 1:10 p.m., Staff #2 (S2) heard banging on the door between the facility and the patio, S2 opened door for the R1, and found R1 with burned jeans and a burned leg. The facility immediately called 9-1-1 and R1 was taken to a general acute care hospital, where he was admitted on April 25, 2020. As staff was aware that R1 required supervision during smoking, provided R1 a cigarette and lighter, and left R1 without supervision, R1 was able to exit the building, light the cigarette, and as a result ignite a piece of clothing and sustained a burn.

On April 30, 2020, R1 underwent surgery at the hospital for treatment of third-degree burns of less than 10% of his body. R1 required skin grafts and on May 18, 2020, R1 was transferred to a Post-Acute Skilled Nursing Facility for rehabilitation following the procedure.

continued on 809-C

SUPERVISOR'S NAME: Alycia Berryman	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Lauren Crocker	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

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 OROVILLE	FACILITY NUMBER: 045002619
	VISIT DATE: 08/05/2021

NARRATIVE

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According to the Mayo Clinic, “a burn is tissue damage resulting from heat, overexposure to sun or radiation, chemical, or electrical contact. More specifically, a third-degree burn is a burn that reaches to the fat layer beneath the skin, may be black, brown, white, or leathery, and third-degree burns can destroy nerves, causing numbness.”

Based on medical records, interviews and a facility record review, facility staff did not provide adequate care and supervision to R1 on April 25, 2020 by ensuring that the facility had a sufficient number of staff available to oversee the activities of R1 and preventing R1 from attempting to smoke unaccompanied. R1 was not monitored which resulted in R1 being able to exit the facility onto the patio area, light a cigarette, ignite R1’s pants/leg, and sustained a burn which required a hospitalization, surgery, and a subsequent stay in a post-acute setting for rehabilitation. R1’s burns that required hospitalization is a serious bodily injury.

At the time of the complaint visit on October 09, 2020, the issuance of a civil penalty was still being determined and the licensee was informed that a civil penalty 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 the serious bodily injury R1 sustained. Per Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a 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 07/23/2021, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violating that the Department constitutes as serious bodily injury in the amount of $10,000.

A copy of the LIC 421D was given to Administrator Terry Brown and originals were signed.

Exit interview conducted. Appeal Rights provided. A copy of the report issued. Administrator Terry Brown signature on this report acknowledges receipt of these rights, found on page 2 of LIC 421D.

SUPERVISOR'S NAME: Alycia Berryman	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Lauren Crocker	TELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2021

LIC809 (FAS) - (06/04)

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