045002773-8-10-2022-25-AS-APEZ-CHBV2W-20220815160351

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045002773
Report Date: 08/09/2022
Date Signed: 08/10/2022 09:52:56 AM

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
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):

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A medical professional's orders were not followed.
Staff did not seek timely medical attention.
Medication dosage is inaccurate.

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 medical professional's orders were not followed, Staff did not seek timely medical attention, and Medication dosage is inaccurate.

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 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)

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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

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A medical professional's orders were not followed (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 on 03/23/22, a medical professional verbally gave an order to a staff person to contact her, to advise if her patient/resident had any type of change or decline in his health. During the course of the conversation, the staff person did not advise the medical professional that the resident had been sick for several days prior, as the staff person indicated that she had been off of work for those few days and was not aware of the resident’s decline in health.

It was reported that the resident had been ill for a few days and on 03/24/22, at approximately 0300 hours, staff observed that the resident had black dark liquid vomit and diarrhea. Two staff persons were on shift; however, neither of them called Emergency Services (911) to have the resident examined. It was stated that in the morning at approximately 0630 hours, the resident was dressed and coming down the hallway when he collapsed, continued to vomit black dark liquid, became unconscious and died.

The facility staff are responsible to notify the resident’s physician when a resident’s mental or physical health changes. Although the staff person acknowledged that she received the verbal order, other staff persons working, were not informed of the verbal order, and no one notified the medical professional of the resident’s decline in health.

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 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: 7 of 7

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

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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.

Staff did not seek timely medical attention (Resident 1).
During the investigative process, seven staff persons, other persons and two residents were interviewed. 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.

It was reported that the resident had been ill for a few days with the flu and on 03/24/22, at approximately 0300 hours, staff observed that the resident had black dark liquid vomit and diarrhea. There were two staff persons on shift; however, neither of them called Emergency Services (911) to have the resident examined. It was stated that it was the responsibility of the lead medication technician that should have called 911. When the medication technician did not call, the backup care provider should have called 911; however, she stated that that it was the responsibility of the medication technician. Neither staff persons contacted 911 and did not seek timely medical attention.

It was stated that in the morning, at approximately 0630 hours, the resident was coming down the hallway when he collapsed, continued to vomit black dark liquid, became unconscious, and died.

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: 5 of 7

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

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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.

In addition, civil penalties in the amount of $500.00 are assessed today for a resident sustaining a serious bodily injury while in care.

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.”

The facility is being advised that under H&S Code §1568.0822(f) the issuance of an Enhanced Civil Penalty (ECP) is currently under review and may be assessed later, due to a resident sustaining (as defined above) serious bodily injury while in care of the facility.

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: 4 of 7

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

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Medication Dosage is Inaccurate (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 allegation were not available for an interview. Numerous documents were obtained to include Physician’s Report, Admission Agreement, Medications List, Resident Roster and Staff Roster.

It was reported that on 11/02/21, a resident’s medication of Losartan Potassium was increased from 1 tablet to 1.5 tablets. In March 2022, it was documented that the resident was only receiving 1 tablet of Losartan Potassium, rather than the prescribed order of 1.5 tablets. Records indicated that the error was corrected on 03/15/22.

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 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 7

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
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 87466	1 2 3 4 5 6 7	Observation of a resident - When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.	1 2 3 4 5 6 7	The administrator agrees to develop a policy that ensures cross training is provided between staff to make certain that coverage is existent when a physician needs to know that a resident has had a change in health condition.
	8 9 10 11 12 13 14	The licensee did not ensure that a resident’s medical professional was notified of a resident’s health change.This poses an immediate Health and Safety risk to residents.	8 9 10 11 12 13 14
Type A 08/10/2022 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	Incidental Medical and Dental Care - The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).	1 2 3 4 5 6 7	The administrator agrees to ensure that all medication technicians and care staff are prepared and trained to know when to contact Emergency Services (911) and when there is a life-threatening medical crisis.
	8 9 10 11 12 13 14	The licensee did not ensure that staff persons called 911 during an incident that caused an imminent threat to the resident’s health. This poses an immediate Health and Safety risk to residents.	8 9 10 11 12 13 14	Civil penalties in the amount of $500.00 are assessed today for a resident sustaining a serious bodily injury while in care.

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 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022

LIC9099 (FAS) - (06/04)

Page: 6 of 7

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
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 87465(a)(5)	1 2 3 4 5 6 7	Incidental Medical and Dental Care - Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. The licensee did not ensure that this requirement was met as evidenced by documentation that reflects an order change; however, was not followed.	1 2 3 4 5 6 7	The administrator agrees to have all of the medication technicians and management trained in ensuring that a physician’s medication change order is followed.
	8 9 10 11 12 13 14	This poses an immediate risk to residents.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 7