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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002773
Report Date: 08/01/2021
Date Signed: 08/01/2021 01:46:19 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:ROSELEAF OROVILLEFACILITY NUMBER:
045002773
ADMINISTRATOR:BROWN, TERRY LFACILITY TYPE:
740
ADDRESS:1900 20TH STTELEPHONE:
(559) 970-1240
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY:60CENSUS: 30DATE:
08/01/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Melissa MillerTIME COMPLETED:
11:15 AM
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On 8/1/21 at 9:20 AM, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced Case Management Health and Safety visit as directed by the department. LPA spoke with Administrator, Terry Brown by phone during the visit. LPA met with Medication technician, Melissa Miller.
Prior to initiating the 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: N-95 mask. Additionally, LPA self screened and temperature checked in the front lobby. New symptom screening and pen holders have been added.
LPA spoke with the Administrator by phone to clarify the following: Facility census is 30 residents- 4 are hospitalized Covid positive, 2 are hospitalized to have symptoms evaluated are confirmed as Covid positive today (bringing the resident total to six(6)) and 2 are in rehab.- 22 residents are present. Current staff are one med tech and one caregiver as a scheduled staff is absent. Staffing plan is for one med tech and two caregivers per shift.
LPA toured the facility inside including but not limited to resident room hallways, facility dining areas and common areas. LPA observed 16 of 22 residents. Care needs were being met. No safety concerns are apparent.
Mitigation recommendations presented by LPA 7/31/21 are in process of implementation.

As a result of this inspection no deficiencies are cited at this time.
Exit interview and report copy provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2021
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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