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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002773
Report Date: 06/08/2022
Date Signed: 06/08/2022 03:14:07 PM


Document Has Been Signed on 06/08/2022 03:14 PM - It Cannot Be Edited

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



FACILITY NAME:ROSELEAF OROVILLEFACILITY NUMBER:
045002773
ADMINISTRATOR:BROWN, TERRY LFACILITY TYPE:
740
ADDRESS:1900 20TH STTELEPHONE:
(530) 538-8200
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY:60CENSUS: 36DATE:
06/08/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee Golden Roseleaf and Peer ServicesTIME COMPLETED:
11:35 AM
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An informal conference was conducted today via Microsoft Teams Platform. The purpose of this informal conference meeting was to discuss sister facility Roseleaf Senior Care and the transition of Licensees. Present in the meeting is Regional Manager Alycia Berryman, Licensing Program Manager Laura Munoz, Licensing Program Analyst Jaclyn Avila, Licensee Raj Rao, Chief of Operations Stephen Ratliff, Audre Smith and Roseleaf Senior Care Administrator Samantha Guarino. The informal conference process was explained during this meeting.

Topics discussed during the meeting were:
· Licensee/Administrator accountability
· Transition as Peer Services separates as Licensee/Management
· Ensuring all staff regardless of position are fingerprint cleared and associated

The following Forms are due by June 10th, 2022 and are to be submitted to LPA
LIC 308

The following Forms are due by June 30th, 2022 and are to be submitted to LPA
Infection Control Plan

Cont'd on LIC 809-C
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
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: 045002773
VISIT DATE: 06/08/2022
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The following Forms are due by July 8th, 2022 and are to be submitted to LPA
LIC 500 Personnel Roster
Resident Roster LIC 9020
LIC 309 and Organizational flow chart

Copy of this report will be e-mailed to the Licensee for Signature and a signed copy will be returned same day to LPA.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC809 (FAS) - (06/04)
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