045002773-7-15-2022-25-AS-APEZ-CLQV2V-20221202150347

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045002773
Report Date: 07/15/2022
Date Signed: 07/15/2022 11:47:06 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
07/11/2022 and conducted by Evaluator Jaclyn Avila

COMPLAINT CONTROL NUMBER: 25-AS-20220711084059

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: 34	DATE:	07/15/2022
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Crystal Cumminskey, Lead MT		TIME COMPLETED:	11:59 PM

ALLEGATION(S):

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Facility not following Covid Safety Precautions
Facility has unsafe water temperatures in resident room

INVESTIGATION FINDINGS:

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On 07/15/2022, Licensing Program Analyst (LPA) Jaclyn Avila conducted an announced complaint investigation visit regarding the above allegations, and Crystal Cumminskey, Lead MT. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 LPA was not screened at the front door.

This Department has conducted an investigation into the above listed allegations and found them to be Substantiated. Upon entering the facility, this Department was greated by staff who was wearing a mask below the nose. This Department was not screened at the front door. Interviews revealed staff are needing to be reminded daily to follow masking requirements.

Cont'd on LIC 9099C

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022

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-20220711084059

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: 07/15/2022

NARRATIVE

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The investigation revealed that a valve on the water heater needs to be replaced and residents nor staff can control the temperature of the water. Due to the inability to control water temperatures and to ensure the safety of residents, the facility has not been showering residents in their own showers but are taking them to a different location in the building to shower which has resulted in some refusals of residents to shower. The water system has been in disrepair for approximately a month and has not been fixed to date. This department observed the Smith Cyclone output temperature of the water to be 125 degrees F.

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

The following deficiencies were cited per Title 22 of the California Code of Regulation (See 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: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20220711084059

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: 07/15/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/16/2022 Section Cited CCR 87464(f)(2)	1 2 3 4 5 6 7	87464 Basic Services - (f) Basic services shall at a minimum include:(2) Safe and healthful living accommodations and services. This requirement is not met as evidenced by: Based upon observation and interview the Licensee failed to	1 2 3 4 5 6 7	Licensee agrees to repair the water heater with in 24 hours. The licensee will provide proof to LPA via e-mail with in 24 hours. Licensee agrees to read regulation 87464 and provide a letter of understanding to LPA via e-mail with in 24 hours to include in procedures to prevent this from occuring again
	8 9 10 11 12 13 14	maintain the water heater which has resulted in the inability to adjust the temperature in residents own showers or sinks. This poses an immediate Health, Safety and/or Personal Rights risk to residents in care.	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: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022

LIC9099 (FAS) - (06/04)

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