045002773-8-9-2022-25-AS-APEZ-CHBV2X-20220815160351

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045002773
Report Date: 08/09/2022
Date Signed: 08/09/2022 01:55:18 PM

Unsubstantiated

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
03/25/2022 and conducted by Evaluator Donna Gurriere

COMPLAINT CONTROL NUMBER: 25-AS-20220325092801

FACILITY NAME:	ROSELEAF OROVILLE		FACILITY NUMBER:	045002773
ADMINISTRATOR:	BROWN, TERRY L		FACILITY TYPE:	740
ADDRESS:	1900 20TH ST		TELEPHONE:	(530) 538-8200
CITY:	OROVILLE	STATE: CA	ZIP CODE:	95965
CAPACITY:	60	CENSUS: 36	DATE:	08/09/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	AMBER FARMER		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff discouraged a medical professional to see a resident.
Questionable Death.

INVESTIGATION FINDINGS:

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

Donna Gurriere, Licensing Program Analyst was in contact and met with Amber Farmer, Assistant Administrator. It was alleged that Staff discouraged a medical professional to see a resident and that there was a Questionable Death.

LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Additionally, LPA Gurriere was screened by a staff person upon entering the facility.

continued

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022

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 3

Control Number 25-AS-20220325092801

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: 045002773
	VISIT DATE: 08/09/2022

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

Staff discouraged a medical professional to see a resident (Resident 1).
During the investigative process, five staff persons and other persons were interviewed. Two staff persons that were working during the time of the incident were not available for an interview. Numerous documents were obtained to include Physician’s Report, Admission Agreement, Medications List, Resident Roster, Death Report, Incident Report, Staff Roster, Police Reports and Fire Department Reports.

During the interview process, it was reported that a medical professional went to the facility to visit a resident. Staff at the facility advised the medical professional that several residents in the facility had flu symptoms and that the resident that she wanted to visit was one of the residents with the flu. The staff stated that they asked the medical professional if she would like to come back another day due to residents having the flu, and the medical professional agreed. It was stated that the medical professional visited on 03/23/22; however, in the early morning of 03/24/22, the resident worsened. The staff did not know that the resident would become worse the day after the medical professional made the visit. Staff did not discourage the medical professional from visiting, but rather advised the medical professional that residents in the facility had the flu.

Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation(s) did or did not occur; therefore, the allegation findings are Unsubstantiated.

continued

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 25-AS-20220325092801

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: 045002773
	VISIT DATE: 08/09/2022

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

Questionable Death (Resident 1).
Throughout the course of the complaint investigation, the department conducted interviews and reviewed documents relevant to the allegation of Questionable Death of a resident. Documents reviewed, revealed that the cause of death was Cardiopulmonary Arrest, Electrolyte Disorder and Dehydration.

It was reported that the questionable death allegation was unsubstantiated due to insufficient information; there was no documentation or facility report available for review to indicate the resident’s internal organs/condition was examined and assessed for the extent of the injury to the resident.

Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation(s) did or did not occur; therefore, the allegation findings are Unsubstantiated.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3