045002773-12-8-2022-25-AS-KHOS-CMLLC9-20221230073757

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045002773
Report Date: 12/08/2022
Date Signed: 12/08/2022 11:19:15 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
10/21/2022 and conducted by Evaluator Kerry Hiratsuka

COMPLAINT CONTROL NUMBER: 25-AS-20221021090833

FACILITY NAME:	ROSELEAF OROVILLE		FACILITY NUMBER:	045002773
ADMINISTRATOR:	FARMER, AMBER		FACILITY TYPE:	740
ADDRESS:	1900 20TH ST		TELEPHONE:	(530) 538-8200
CITY:	OROVILLE	STATE: CA	ZIP CODE:	95965
CAPACITY:	60	CENSUS: 32	DATE:	12/08/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Amber Farmer		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility laundry equipment is in disrepair
Staff is not ensuring laundry services are being provided
Window screens are not maintained and in good repair

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: Facility laundry equipment is in disrepair; Staff is not ensuring laundry services are being provided; Window screens are not maintained and in good repair.
LPA conducted interviews and toured the facility. The main facility laundry clothes dryer stopped working. Administrator was able to purchase two new ones, but it took two weeks for it to arrive. In the mean time, the laundry was not being done for about a week until staff started using another clothes dryer that was opened up for staff usage. The facility did not send any laundry to the laundry mat to prevent the dirty laundry from piling up in the beginning. Some of the window screens were removed prior to the visit due to them requiring repairs.
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 Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (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 5

Control Number 25-AS-20221021090833

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 B 01/08/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This is evidenced by: Licensee failed this by: not having a plan for when the	1 2 3 4 5 6 7	By 01/08/2023, the licensee shall submit a written plan of correction on how they shall maintain laundry services if the machines stop working and how they shall maintain the window screens.
	8 9 10 11 12 13 14	laundry machines stop working and the dirty laundry not being done. The window screens requiring repairs not being done timely. This is a potential risk to the health and safety of the resident.	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: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (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 5

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
10/21/2022 and conducted by Evaluator Kerry Hiratsuka

COMPLAINT CONTROL NUMBER: 25-AS-20221021090833

FACILITY NAME:	ROSELEAF OROVILLE		FACILITY NUMBER:	045002773
ADMINISTRATOR:	FARMER, AMBER		FACILITY TYPE:	740
ADDRESS:	1900 20TH ST		TELEPHONE:	(530) 538-8200
CITY:	OROVILLE	STATE: CA	ZIP CODE:	95965
CAPACITY:	60	CENSUS: 32	DATE:	12/08/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Amber Farmer		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff speaks inappropriately at residents
Hallways are not properly lit

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 speaks inappropriately at residents, and Hallways are not properly lit.

LPA conducted multiple staff interviews. LPA was unable to interview residents based on mental capacity. A couple of interviews stated the staff might have spoken inappropriately at residents, but couldn't prove it. All others stated they haven't heard any staff speaking inappropriately.

LPA toured the facility and interviewed staff. LPA cannot prove or disprove the hallways are not properly lit.

Based on the above, the allegations cannot be proved or disproved and therefore unsubstanitated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (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 5

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
10/21/2022 and conducted by Evaluator Kerry Hiratsuka

COMPLAINT CONTROL NUMBER: 25-AS-20221021090833

FACILITY NAME:	ROSELEAF OROVILLE		FACILITY NUMBER:	045002773
ADMINISTRATOR:	FARMER, AMBER		FACILITY TYPE:	740
ADDRESS:	1900 20TH ST		TELEPHONE:	(530) 538-8200
CITY:	OROVILLE	STATE: CA	ZIP CODE:	95965
CAPACITY:	60	CENSUS: 32	DATE:	12/08/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Amber Farmer		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility floor presents a trip hazard
Facility did not provide staff with PPE during an outbreak

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: Facility floor presents a trip hazard, and Facility did not provide staff with PPE during an outbreak.

LPA toured the facility. There is a section of flooring that looks like it is in disrepair, but it does not pose a tripping hazard. There are no raised areas that feet can get caught on. The floor, when viewed from certain angles appears to be bubbling, but when walking on it or touching it, the bubbles do not appear. The floor is still smooth. The allegation is unfounded.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (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: 4 of 5

Control Number 25-AS-20221021090833

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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LPA interviewed staff. All stated there was more than enough personal protection equipment supplied by the facility during outbreaks and the equipment was available in multiple carts that were placed throughout the facility.

“This agency has investigated the complaint alleging; Facility floor presents a trip hazard and Facility did not provide staff with PPE during an outbreak We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (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: 5 of 5