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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002773
Report Date: 06/01/2023
Date Signed: 06/01/2023 10:48:17 AM


Document Has Been Signed on 06/01/2023 10:48 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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: 29DATE:
06/01/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Amber Farmer - administratorTIME COMPLETED:
11:00 AM
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06/01/02023 9:30 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Administrator Amber Farmer. Today’s visit is regarding an incident that occurred on 05/26/2023 and was reported to licensing on 05/26/2023. It was reported that during staff rounds, a resident was found with a cup of laundry detergent and laundry detergent around their mouth. 911 was called immediately, the resident was transported to the hospital and subsequently hospitalized for observation. Resident is now back in the facility and doing well. Staff have increased observation of the resident.

During the course of the investigation, it was learned that the laundry room is located in the “upper” portion of the facility. The laundry room door has an auto lock, and locks when shut. Staff do not know how the resident gained access to the detergent. All employees who were on duty stated the laundry room door was shut. There were no witnesses.

As a result of the incident the facility has installed a spring hinge on the laundry room door and plans to additionally install locks on the cabinets in the locked laundry room where laundry detergent will be stored.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to administrator Amber Farmer.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023
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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Document Has Been Signed on 06/01/2023 10:48 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833


FACILITY NAME: ROSELEAF OROVILLE
FACILITY NUMBER: 045002773

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/15/2023
Section Cited
CCR
87705(f)(2)

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87705(f)(2) Care of Persons with Dementia - (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
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Licensee has installed a spring hinge to the laundry room doors. In addition licensee will conduct a training for all staff on the requirement to ensure that all cleaning toxins are stored inaccessible to residents. Licensee will schedule the training and provide LPA with the training content and signed staff attendance sheet as the POC.
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Based on interviews, it was determined that Resident 1 gained access to a laundry room and was found by staff with a cup of laundry detergent in their hand and laundry detergent around their mouth. This poses an immediate health and safety risk to residents in care.
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The proof of correction is to be received by LPA Knight by 06/15/2023.

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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: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023
LIC809 (FAS) - (06/04)
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