045002773-1-28-2021-25-AS-JAVA-BXQ37P-20210128170017

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 045002773
Report Date: 01/28/2021
Date Signed: 01/28/2021 05:01:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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:	045002773
ADMINISTRATOR:	BROWN, TERRY L		FACILITY TYPE:	740
ADDRESS:	1900 20TH ST		TELEPHONE:	(559) 970-1240
CITY:	OROVILLE	STATE: CA	ZIP CODE:	95965
CAPACITY:	60	CENSUS: 34	DATE:	01/28/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:01 AM
MET WITH:	Administrator Terry Brown		TIME COMPLETED:	01:30 PM

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	Licensing Program Analyst (LPA) Jaclyn Avila conducted a Pre-Licensing inspection of the facility via Facetime with Administrator Terry Brown. Inspection was done via tele-visit due to COVID 19 precautions. The Facility consist of two buildings. The main building consists of 1 kitchen, 19 bathroom(s), 2 dining room, 3 living rooms, 2 laundry rooms, and 30 bedrooms. The building referred to as the cottage consists of 1 kitchen, 2 bathrooms, 1 dining room, 1 living room, 1 laundry room and 3 bedrooms for a capacity of 5. The facility has requested licensure for a capacity of 60 residents (0 ambulatory, 60 non-ambulatory, 15 bedridden and 15 hospice). Currently there are 34 residents in care at the facility. LPA Avila toured the facility with the administrator Terry Brown. The physical plant is consistent with the submitted facility sketch/floor plan. The facility is clean and in good repair. The facility temperature is between 68 degrees and 74 degrees. All window screens are clean and in good repair. There is appropriate lighting in the facility and in each room. There is a locked centralized storage area for resident medications. Protective devices are in use such as non-slip material on rugs. Indoor and outdoor passageways and stairways are free of obstruction. Stairways, inclines, ramps, open porches, and areas of potential hazard accessible to residents are well-lit and equipped with sturdy hand railings. Disinfectants, cleaning solutions, poisons, and other items which could pose a danger are inaccessible. Fire alarms and smoke alarms operate properly. Carbon monoxide detectors operate properly. Resident bedrooms are large enough to allow for easy passage between and comfortable usage of beds and other required items of furniture, and any resident assistant devices such as wheelchairs or walkers. There is a bed for each resident equipped with good springs, clean and comfortable mattress, pillow(s), and bedding. Mattresses and pillows are flame retardant. There is a chair, night stand, chest of drawers, and lamp or sufficient lighting for each resident. There is at least eight (8) cubic feet of drawer space for each resident.

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2021

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 COHASETT RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ROSELEAF OROVILLE	FACILITY NUMBER: 045002773
	VISIT DATE: 01/28/2021

NARRATIVE

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Bathroom floors are clean and sanitary. All bathtubs, showers, and toilets have grab bars. All bathtubs and showers have non-skid mats or strips. All bathtubs, showers, toilets, and sinks operate properly. There is a sufficient supply of hygiene items such as soap and toilet paper. There is a sufficient supply of clean linen, including blankets, bedspreads, top sheets, bottom sheets, pillowcases, bath towels, hand towels, and wash cloths, to permit changing weekly or more often as needed.

Kitchen and dining room floors are clean, sanitary, and odorless. Trash cans have tight fitting covers. Kitchen areas are clean and free of litter, rodents, vermin and insects. There are no pesticides, poisons, or other toxic substances stored in any food storage or preparation area or with utensils. Cleaning supplies are kept in areas separate from food supplies. Freezer is below 0 degrees Fahrenheit. The refrigerator is at approximately 40 degrees Fahrenheit. A seven (7) day supply of non-perishable food is present. There are sufficient amounts of tableware, tables, dishes, and utensils. There are sufficient amounts of equipment for the storage, preparation, and service of food. All equipment, fixed or mobile, and dishes, are clean and in good repair with no breaks, open seams, cracks or chips.

There is confidential storage of personnel records at the facility. There is confidential storage of resident records at the facility.

Facility Theft and Loss Program is posted. The Licensing Complaint Poster is posted. Resident Personal Rights are posted. Posting Title 22, Section 87468 and Health and Safety Code, Section 1569.269 meets this requirement. Resident Council Rights are posted. Posting a copy of the Rights of Resident Councils PUB 747 meets this requirement.

There are activity supplies and equipment, including access to daily newspapers, current magazines, and a variety of reading materials. There is an outdoor activity area equipped for outdoor use. There is a comfortable and appropriately furnished area such as a living room for residents to entertain friends and relatives.

There is a first aid kit, including sterile dressings, bandages, thermometer, scissors, tweezers, and a current first aid manual. There are laundry supplies and equipment, including at least one machine in good repair. There is a space for clean linen storage and a separate space for soiled linen.

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2021

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 COHASETT RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ROSELEAF OROVILLE	FACILITY NUMBER: 045002773
	VISIT DATE: 01/28/2021

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There is an operating telephone available to residents. Emergency lighting supplies e.g., flashlights, batteries are present. Vehicles used to transport residents are in safe operating condition.

DEMENTIA CARE
Knives, matches, tools and other items that could constitute a danger are inaccessible. Over the counter medications, nutritional supplements or vitamins, alcohol, and cigarettes are inaccessible. Toxic substances such as certain plants, gardening supplies, cleaning supplies, and disinfectants are inaccessible. Outdoor activity space is completely enclosed by a fence with self-closing latches and gates, or walls. Auditory devices are in place to monitor exits, if exiting presents a hazard to any resident.

LPAs observations of deficiency are as following:

Room 3 at 1025 AM

Closet was locked that contained resident’s clothes. Closet contained personal hygiene items. LPA Discussed moving hygiene items to locked cabinet in bathroom so that the closet can be left unlocked. LPA did not observe a mattress pad

Room 4 at 1032 AM cabinet left unlocked with personal hygiene items. Bed does not have a mattress pad. LPA discussed having mattress pads that are fire retardant and in every resident room.

LPA discussed with Administrator the importance of locking up personal hygiene items in a memory care unit as there is a possibility the LIC 602 (physicians report) may reflect access can pose a hazard to resident in care.

Administrator will have mattress pads for all beds by Feb 8^th, 2021.

The hot water temperature are not between 105-120 degrees Fahrenheit. Upper hall water measured at 101 degrees and Cottage is at 121degrees. Administrator will make adjustments and monitor daily for a week.

No deficiencies were cited at todays tele-visit. Pre-Licensing is incomplete with deficiencies to be resolved by Feb 8^th, 2021

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:	DATE: 01/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2021

LIC809 (FAS) - (06/04)

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