045002773-8-9-2022-25-AS-APEZ-CHBTHV-20220815144517

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045002773
Report Date: 08/09/2022
Date Signed: 08/09/2022 02:13:03 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
05/16/2022 and conducted by Evaluator Donna Gurriere

COMPLAINT CONTROL NUMBER: 25-AS-20220516120548

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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Resident was attacked by another resident.
Residents' are left in incontinence products.
A resident entered another resident’s room undressed.

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 was attacked by another resident, Residents' are left in incontinence products and A resident entered another resident's room undressed.

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-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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Resident 1 was attacked by Resident 2.
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, and the Resident’s Assessment document.

During the interview process, overall, staff persons reported that they were not aware of an incident where Resident 1 was attacked by Resident 2. It was reported that Resident 2 “threatened” staff with a fork and knife; however, no physical contact was made.
Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated.

Residents' are left in incontinence products.
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, and the Resident’s Assessment document.

During the interview process, most staff persons reported that residents are checked for soiled incontinence products every two hours and that staff follow a schedule for checking on the residents. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the 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)

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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 2) entered another resident’s room (Resident 1) undressed.
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, and the Resident’s Assessment document.

During the interview process, staff persons reported that they did not witness resident 2 enter into resident 1’s room undressed. It was reported that resident 2 at times would undress, but he was not observed undressed in resident 1’s room. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the 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)

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