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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002773
Report Date: 08/09/2022
Date Signed: 08/09/2022 02:29:55 PM

Substantiated


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
05/16/2022 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 25-AS-20220516120548
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:
08/09/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:AMBER FARMERTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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A resident sustained multiple falls at the facility.
Staff did not seek medical attention for a resident in a timely manner.
A resident's belongings were misplaced.
INVESTIGATION FINDINGS:
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Donna Gurriere, Licensing Program Analyst was in contact and met with Amber Farmer, Assistant Administrator. It was alleged that A resident sustained multiply falls at the facility, Staff did not seek medical attention for a resident in a timely manner and A resident's belongings were misplaced.

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
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (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 6
Control Number 25-AS-20220516120548
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
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A resident (Resident 1) sustained multiple falls at the facility.
During the investigative process, the assistant administrator, six staff persons and other persons were interviewed. Various documents were obtained and reviewed to include Physicians Report, Admission Agreement, Incident Reports, Activities of Daily Living Basic Care Services, Appraisal/Needs and Services Plan, the Resident’s Assessment document and photos.

It was reported and verified by Incident Reports that a resident did sustain multiple falls at the facility. In one fall, it was reported that the resident suffered a head injury and a black eye (photo reviewed). The facility completed the Activities of Daily Living Basic Care Services for the resident. The checklist for item #3 states “How much assistance does the resident require with mobility and transfers?” A check mark is listed for “Walks with supervision or ambulation devise.” In addition, the resident’s Physician Report states that the resident has “Motor Impairment/Paralysis from post hip surgery, need assistance.” On the Appraisal/Needs and Services Plan it is stated “Functioning Skills – Difficulty in developing and/or using independent functioning skills, cannot function on own.” Three different documents supported that the resident was a fall risk and needed assistance and supervision when walking.

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be Substantiated. California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (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: 6 of 6
Control Number 25-AS-20220516120548
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
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Staff did not seek medical attention for a resident (Resident 1) in a timely manner.
During the investigative process, the assistant administrator, six staff persons and other persons were interviewed. Various documents were obtained and to include Physician’s Report, Admission Agreement, Incident Reports, Activities of Daily Living Basic Care Services, Appraisal/Needs and Services Plan, the Resident’s Assessment document and photos.

It was reported and verified by Incident Reports that a resident did sustain multiple falls at the facility. It was reported in a fall, during the nighttime shift, the resident fell and suffered a skin tear from her wrist to near elbow (photos reviewed). It was reported that the staff person did not contact Emergency Services (911); however, rather bandaged the skin tear herself. Several hours went by before the morning shift arrived, observed the seriousness of the skin tear wound and sent the resident out to the hospital.

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be Substantiated. California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D

continued

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (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 6
Control Number 25-AS-20220516120548
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
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A resident's (Resident 1) belongings were misplaced.
During the investigative process, the assistant administrator, six staff persons and other persons were interviewed. Various documents were obtained to include Physician’s Report, Admission Agreement, Incident Reports, Activities of Daily Living Basic Care Services, Appraisal/Needs and Services Plan, Personal Property and Valuables document and the Resident’s Assessment document.

Most staff and others reported that the residents at the facility have dementia and that they do have a tendency to walk away with other resident’s items. The Property and Valuables List document was reviewed, and it did not have the resident’s items listed, but rather a “slash” through the document and the Power of Attorney’s (POA) signature. A list of the resident’s items were not listed. It was reported that when the resident moved out, her belongings were misplaced and were not available for her to take them with her, which included some garments and shoes. The facility staff reported that they have obtained some of the resident's items and are available to be picked up at the front office.

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be Substantiated. California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D.

Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (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: 4 of 6
Control Number 25-AS-20220516120548
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/10/2022
Section Cited
CCR
87464(f)(1)
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Basic Services - Basic services shall at a minimum include: Regular observation of the resident's physical and mental condition, as specified in Section 87466, Observation of the Resident.

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The assistant administrator agrees to assess all residents that are a fall risk. The assistant administrator shall develop a system in place to assist in preventing residents from falls and agrees to submit the plan of correction to the licensing agency
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The licensee did not ensure that this requirement was met as evidenced by interviews and records review in that it was documented in several places that the resident needed assistance and supervision when walking. This poses an immediate risk to residents in care.
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Type A
08/10/2022
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care - The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
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The assistant administrator agrees to provide training to all care providers and medication technicians, as to the importance of when it is appropriate to send a resident to the hospital. Names and staff signatures and training dates shall be sent to the licensing agency.

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The licensee did not ensure that this requirement was met as evidenced by interviews and record reviews in that a staff person working the nighttime shift did not contact Emergency Services (911) when a resident fell and sustained a large skin tear on her arm. This poses an immediate risk to residents in care.
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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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 25-AS-20220516120548
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2022
Section Cited
CCR
87217(b)
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 Safeguards for Resident Cash, Personal Property, and Valuables - Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff.
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The assistant administrator agrees to ensure that resident’s belongings are listed on the Property and Valuables document. The assistant administrator shall update her records for at least 13 residents and shall submit a copy to the licensing agency.
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The licensee did not ensure that this requirement was met as evidenced by interviews and record reviews in that when the resident left the facility, she did not receive all of her belongings. This poses a potential risk to resident’s in care.
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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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6