045002773-1-10-2023-25-AS-KHOS-CN8LVD-20230119080522

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045002773
Report Date: 01/10/2023
Date Signed: 01/10/2023 10:38:42 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
07/13/2022 and conducted by Evaluator Donna Gurriere

COMPLAINT CONTROL NUMBER: 25-AS-20220713105249

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: 37	DATE:	01/10/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	AMBER FARMER		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Facility hallway floors are unclean.

INVESTIGATION FINDINGS:

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Donna Gurriere, Licensing Program Analyst was in contact and met with Amber Farmer, Administrator. Allegation is in regard to Facility hallway floors are unclean.

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: Surgical mask. Additionally, LPA Gurriere was screened by a staff person upon entering the facility.

continued

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023

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-20220713105249

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: 01/10/2023

NARRATIVE

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Facility hallway floors are unclean.

On 7/18/2022 at approximately 3:15 p.m., during a health and safety check, Jaclyn Avila, LPA noted that there were large stains on the carpeted floors off of the community area. LPA also observed liquid on the laminate floors. Floors were not clean.

Based on LPAs observations, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be Substantiated. California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D.

Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20220713105249

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: 01/10/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/17/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times… The licensee did not ensure that this requirement was met as evidenced by observations. Large stains were noted on the carpeted floors and liquid was observed on the laminate floors.	1 2 3 4 5 6 7	The administrator agrees to ensure that the floors are maintained and kept clean. The administrator shall submit to the licensing agency a policy advising how to ensure that the floors are maintained and are clean.
	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
	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: Anthony Perez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023

LIC9099 (FAS) - (06/04)

Page: 5 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
07/13/2022 and conducted by Evaluator Donna Gurriere

COMPLAINT CONTROL NUMBER: 25-AS-20220713105249

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:	DATE:	01/10/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	AMBER FARMER		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Resident was hospitalized for dehydration.

INVESTIGATION FINDINGS:

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Donna Gurriere, Licensing Program Analyst was in contact and met with Amber Farmer, Administrator. Allegation is in regard to Resident was hospitalized for dehydration.

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: Surgical mask. Additionally, LPA Gurriere was screened by a staff person upon entering the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023

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

Control Number 25-AS-20220713105249

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: 01/10/2023

NARRATIVE

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Resident was hospitalized for dehydration.

During the investigation, the administrator and five staff persons were interviewed. The resident was not interviewed, as she no longer resides at the facility. Documents obtained for the investigation included Physician’s Report, Care Report, Residence/ Care Agreement and staffing names with telephone numbers.

During the interview process, it was reported that the resident (Resident 1) was having a hard time breathing and was therefore sent to the hospital from the facility. Staff indicated that they did not see signs of dehydration of the resident in that she generally drank fluids. It was reported that staff pass water at breakfast, lunch, dinner and snack times. It was also stated that the facility has water stations set up at all times, in two parts of the facility for residents to get water. Overall, it was reported that staff were not aware that the resident was dehydrated; but rather the resident went to the hospital for breathing issues. Although the resident may have been dehydrated, the staff indicated that they did their due diligence by offering water to the residents during meal and snack times and also having two water stations available for all 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.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023

LIC9099 (FAS) - (06/04)

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