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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002773
Report Date: 12/08/2022
Date Signed: 12/08/2022 11:22:48 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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
10/05/2022 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 25-AS-20221005124451
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: 32DATE:
12/08/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Amber FarmerTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff negligence resulted in hospitilzation of resident
Medication not given as prescribed
INVESTIGATION FINDINGS:
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LPA Hiratsuka, conducted the investigation into the allegations above. LPA wore a surgical mask during visit and observed all staff wearing surgical masks.
LPA Hiratsuka investigated the allegations: Staff negligence resulted in hospitilzation of resident, and medication not given as prescribed.

LPA interviewed staff and reviewed resident records. Based on the investigation the resident was given the wrong medication and sent to the hospital as a precaution. While at the hospital the resident was diagnosed with a urinary tract infection and dehydration. This was not observed by staff.

Based on the above, the allgation is substantiated.
Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code. Failure to correct shall result in civil penalties.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
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 4
Control Number 25-AS-20221005124451
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/09/2022
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with
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By 12/09/2022, the licensee shall submit a writing on the plan to prevent medication errors in the future.
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self-administered medications as needed. This is evidenced by: Licensee failed this by a resident being given the wrong medication and as a result the resident was sent to the hospital. This is an immediate risk to the health and safety of the resident.
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Type A
12/09/2022
Section Cited
HSC
1569.312(e)
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Basic services requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services:Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being.
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By 12/09/2022, the licensee shall submit a written plan of correction regarding staff training on the signs and symptoms of resident with urinary tract infections and dehydration.
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Licensee failed this by a resident being sento the hospital and being diagnosed with a urinary tract infection and dehydration that the staff did not observe. This is an immedate health and safety risk to residents
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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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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
10/05/2022 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 25-AS-20221005124451

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: 32DATE:
12/08/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Amber FarmerTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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1. Facility did not provide documentation to POA within 2 business days
2. Facility failed to contact doctor or palliative care
INVESTIGATION FINDINGS:
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LPA Hiratsuka, conducted the investigation into the allegations above. LPA wore a surgical mask during visit and observed all staff wearing surgical masks.

LPA Hiratsuka investigated the allegations: 1. Facility did not provide documentation to POA within 2 business days, and 2. Facility failed to contact doctor or palliative care

LPA reviewed the resident files. Title 22 regulations and the CA Health and Safety Code both have sections regarding communcations with responsible parties. CA Health and Safety Code Section ยง1569.269(a)(21) Enumerated rights; severability, states, "Residents of residential care facilities for the elderly shall have all of the following rights: To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies."
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 25-AS-20221005124451
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/08/2022
NARRATIVE
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What the section does not state is when the Two Business days start. The responsible party was given a written copy four days after the event, but there is no documentation of when the report was requested. LPA cannot prove or disprove the time between the request and the time it was sent.


2. Title 22 regulations section Reporting Requirements 87211(a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. The facility did fax a notification to the doctor within the seven days of the event occurring. What LPA cannot determine is if the notification should have occurred sooner based on the above regulation.

Based on the above, both allegations cannot be proved or disproved. Allegations are unsubstantiated.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4