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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002773
Report Date: 10/12/2022
Date Signed: 10/12/2022 06:24:20 PM


Document Has Been Signed on 10/12/2022 06:24 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:ROSELEAF OROVILLEFACILITY NUMBER:
045002773
ADMINISTRATOR:FARMER, AMBERFACILITY TYPE:
740
ADDRESS:1900 20TH STTELEPHONE:
(530) 538-8200
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY:60CENSUS: 35DATE:
10/12/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:12 AM
MET WITH:Crystal Cumminskey
Amber Farmer		TIME COMPLETED:
06:45 PM
NARRATIVE
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On 10/12/2022 at 11AM, Licensing Program Analyst (LPA) Jaclyn Avila conducted an unannounced case management visit related to an incident report received by CCLD (Community Care Licensing Division) reporting an AWOL that occurred on 9/10/22. LPA met with Staff Crystal Cumminskey and Administrator Amber Farmer.

The incident report provided that on 9/10/2022 at approximately 4:50PM, facility staff could not located Resident 1 (R1). Staff conducted a search of the interior and exterior of the building to no avail. Incident report states to mitigate the issue, facility will get palliative care more involved to have extra eyes on R1. In addition staff were trained on AWOL procedures and checked on R1 hourly.

The Department spoke with staff who stated R1's Son in law, who is a fireman was in the area for a fire, saw R1 walking down Grand Ave and recognized R1 at which time he brought R1 back to the community. R1 exited the building through the cafe window which leads into the fenced yard for the facility. At the time of the AWOL, the facilities maintenance employee left a perimeter gate to the facility opened. R1 was able to elope through that gate. R1 left undetected for approximately 45 minutes and staff did not know R1 was gone. R1 last eloped from the building approximately 6 months ago through a perimeter gate (ref complaint 25-AS-20220711103123)

The Department reviewed R1's LIC 602 which indicates R1 has a diagnoses of dementia and is unable to leave the facility unassisted.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 341-4932
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022
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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Document Has Been Signed on 10/12/2022 06:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: ROSELEAF OROVILLE
FACILITY NUMBER: 045002773

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/13/2022
Section Cited

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87705(c)(4) Care of Persons with Dementia-Licensees who accept and retain residents with dementia shall be responsible for ensuring: There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs.
This requirement is not met as evidenced by:
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Based upon observation and interview the Licensee failed to provide enough care staff to ensure the safety and health care needs of 1 of 1 residents who had a history of AWOL.

This poses an immediate Health, Safety and/or Personal Rights risk to residents in care.
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Civil Penalty assessed in the amount of $250 due to repeat violation. Previous citation issued on 7/15/22
Type A
10/13/2022
Section Cited

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87555 General Food Service Requirements(b) The following food service requirements shall apply:(29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips.

This requirement is not met as evidenced by:
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Based upon observation and interview the Licensee failed to keep 4 of 4 sinks in the kitchen from leaking and creating water damage and mold.

This poses an immediate Health, Safety and/or Personal Rights 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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 341-4932
LICENSING EVALUATOR SIGNATURE:
DATE: 10/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/12/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: ROSELEAF OROVILLE
FACILITY NUMBER: 045002773
VISIT DATE: 10/12/2022
NARRATIVE
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On 10/12/2022, LPA made the following observations during a tour of the facility with Administrator Amber Farmer:

At 2:15 PM, LPA observed R2 to be in room #18 asleep on R3's bed unsupervised. R2 does not reside in R3's room. R3 was hesitant to go into R3's room due to R2 being in there. At 2:25 PM, LPA observed R4 to be in room #22 belonging to R5. In room #22 LPA observed Febreze. In Room #22 bathroom cabinet LPA observed a razor.

At 2:15PM, LPA observed R2 to have bandages around both forearms. Administrator stated R2 has had many unwitnessed falls which have resulted in injuries. R2 is currently on hospice (effective July 27, 2022).

At 2:27 PM, LPA observed R6 to be walking down the hall with bandaging on R6's right forearm which R6 was holding up with R6 left hand. R6 had yellowed colored bruising above right eye that covered half of R6's forehead and yellow bruising over R6 nose. R6 had dark blue and purple bruising below left eye and above eye brow. Skin tears were observed on left temple and left wrist. LPA observed R6's right sock to have holes that R6's toe stuck out of. Administrator states there were falls on 8/12/22, 9/22/22 and on 10/4/22. The falls on 8/12 and 9/22 were unwitnessed and resulted in a ER visit and bruising to the face. R6 was admitted to hospice on 10/11/22.

Currently there are 5 residents on hospice at the facility.

Administrator agreed with LPA that the acuity of residents is high at this time and there needs to be an increase of staff. The licensee has stipulated with the administrator that there has to be an increase in the number of residents to increase the number of staff. LPA discussed with Amber that if there are insufficient staff whether its due to number of staff or competence of staff, then it would be in the facility's best interest to stop admitting new residents until the facility can meet the needs of all residents in care. LPA went over 87411 CCR with Amber and discussed that there has to be sufficient staff to meet the needs of residents.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 341-4932
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: ROSELEAF OROVILLE
FACILITY NUMBER: 045002773
VISIT DATE: 10/12/2022
NARRATIVE
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At 2:35PM, LPA observed a leak and standing water under the sink connected to the garbage disposal in the kitchen of the facility. LPA observed water damage, mold and rust under the dishwasher machine. In the sink next to the pantry, LPA observed mold in the sink and a pipe leaking connected to the sink. Under the sink was red bucket catching the leaking water. The bucket had standing water. LPA observed silver tape around this pipe that was peeling off. Under the sink by the ice machine, LPA observed water damage, and mold. Under the sink that was identified as the sink produce is washed in across from the stove, LPA observed a leaking pipe and mold along the pipe and the wall behind the sink. LPA could smell the mold.

Administrator stated that someone certified to test for mold had not been out.

During the tour, LPA identified a resident that did not seem to have the same capacity as the other residents. LPA requested the LIC 602 for R7. R7 has a primary diagnosis of Bipolar disorder per LIC 602 dated 5/10/22. This admit was completed by the previous administrator. LPA discussed regulation 87705(I)(7) CCR with Amber. Amber agrees to complete an audit of resident's primary diagnosis and address it to bring the facility into compliance. Amber agrees to conduct the audit no later that 10/14/22 and will reach out to CCL for guidance.

The following deficiencies were cited per Title 22 of the California Code of Regulation (See LIC 809D). 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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 341-4932
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
LIC809 (FAS) - (06/04)
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