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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002773
Report Date: 07/15/2022
Date Signed: 07/15/2022 11:51:40 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/11/2022 and conducted by Evaluator Jaclyn Avila
COMPLAINT CONTROL NUMBER: 25-AS-20220711103123
FACILITY NAME:ROSELEAF OROVILLEFACILITY NUMBER:
045002773
ADMINISTRATOR:BROWN, TERRY LFACILITY TYPE:
740
ADDRESS:1900 20TH STTELEPHONE:
(530) 538-8200
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY:60CENSUS: 37DATE:
07/15/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Crystal Cumminskey, Lead MT TIME COMPLETED:
11:59 PM
ALLEGATION(S):
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A resident eloped from the facility
Facility A/C is in disrepair
Facility water system is in disrepair
Facility fire alarm system is in disrepair
Facility gate is in disrepair


INVESTIGATION FINDINGS:
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On 07/15/2022, Licensing Program Analyst (LPA) Jaclyn Avila conducted an announced complaint investigation visit regarding the above allegations, and Crystal Cumminskey, Lead MT. Prior to initiating the complaint 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: N95 LPA was not screened at the front door.

Cont'd on LIC 9099-C
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/11/2022 and conducted by Evaluator Jaclyn Avila
COMPLAINT CONTROL NUMBER: 25-AS-20220711103123

FACILITY NAME:ROSELEAF OROVILLEFACILITY NUMBER:
045002773
ADMINISTRATOR:BROWN, TERRY LFACILITY TYPE:
740
ADDRESS:1900 20TH STTELEPHONE:
(530) 538-8200
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY:60CENSUS: 37DATE:
07/15/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Crystal Cumminskey, Lead MT TIME COMPLETED:
11:59 PM
ALLEGATION(S):
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Facility fire extinguishers are expired
INVESTIGATION FINDINGS:
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On 07/15/2022, Licensing Program Analyst (LPA) Jaclyn Avila conducted an announced complaint investigation visit regarding the above allegations, and Crystal Cumminskey, Lead MT. Prior to initiating the complaint 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: N95 LPA was not screened at the front door.

This Department toured the facility and observed 4 fire extinguishers. All had been serviced this year and were not expired. Calfire confirmed extinguishers were inspected in 2020 however due to COVID were not able to conduct an inspection in 2021.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 25-AS-20220711103123
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: ROSELEAF OROVILLE
FACILITY NUMBER: 045002773
VISIT DATE: 07/15/2022
NARRATIVE
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This Department has investigated the above listed allegations and found them to be substantiated. This Department has conducted interviews and made observations during a tour of the facility on 7/15/2022.

Allegation: A Resident (R1) eloped from the facility. This Department conducted staff interviews which revealed R1 was located outside of the facility by a different resident’s family. Although R1 was not witnessed leaving the building, staff interviewed believed it was through a gate in which the egress was not working. The mechanism in the gate needed to be repaired and the gate door would swing open. The facility placed pots and chairs to prevent the gate from opening. After the elopement, the facility utilized a cable to lock the gate. This Department requested a copy of the incident report. Staff present during the site visit on 7/15/2022 where unable to provide a copy. This Department contacted the administrator who stated she thought she sent the unusual incident report regarding the elopement of R1 however the facilities internet has been working off and on. No staff were able to provide the date of occurrence, but all confirmed it happened during interview. This department reviewed R1’s physicians report dated 3/30/2022 which is marked that R1 can not leave the facility unassisted.

Allegation: Facility A/C is in disrepair- This Department conducted interviews with facility staff to include administrator. The investigation revealed that the A/C has been broken for approximately a month. The facility has reached out to their vendor and were told the unit needed to be replaced. To date the air conditioning unit has not been fixed nor replaced.

Allegation: Facility water system is in disrepair. The investigation revealed that a valve on the water heater needs to be replaced and residents nor staff can control the temperature of the water. Due to this, residents affected have not been showering in their own shower but are taken to a different location in the building to shower which has resulted in some refusals of residents to shower. The water system has been in disrepair for approximately a month and has not been fixed to date.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 25-AS-20220711103123
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: ROSELEAF OROVILLE
FACILITY NUMBER: 045002773
VISIT DATE: 07/15/2022
NARRATIVE
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Allegation: Fire alarm system is in disrepair. In June of 2022, Roseleaf Oroville experienced the fire alarm system malfunctioning at which time they reached out to the vendor who inspected the system. The vendor recommended the system be replaced due to the system being antiquated and provided the invoice to the administrator who provided it to the Chief Operating Officer for the licensee. To date the system has not been replaced as recommended. Deputy Fire Marshal joined this department in a tour of the facility and strongly recommended the fire alarm system be replaced. Three egress lighting units did not function during the inspection on 7/15/2022 at 3:50 PM. These lights are instrumental in the event there is a power outage.

Allegation: Gate is in disrepair. During a tour of the facility this Department observed that the gate is being secured by a cable and lock. This cable and lock were not implemented until an elopement of a resident occurred. The mechanism securing the gate has been in disrepair since May 2022 and has not been fixed to date.

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.

The following deficiencies were cited per Title 22 of the California Code of Regulation (See LIC 9099D ). Appeal Rights were explained and provided to the facility representative listed above and an Exit Interview was conducted. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 25-AS-20220711103123
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ROSELEAF OROVILLE
FACILITY NUMBER: 045002773
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/16/2022
Section Cited
CCR
87705(c)(4)
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87705(c)(4) Care of Persons with Dementia-Licensees who accept and retain residents with dementia shall be responsible for ensuring: There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs.
This requirement is not met as evidenced by:
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Licensee agrees to increase staffing levels during each shift to ensure the safety and health care needs of all residents. Licensee will provide staffing plan by 5pm on 7/16/2022 to LPA via e-mail. Licensee will provide daily schedules to LPA for the remainder of July 2022.
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Based upon observation and interview the Licensee failed to provide enough care staff to ensure the safety and health care needs of 1 of 1 residents.

This poses an immediate Health, Safety and/or Personal Rights risk to residents in care.
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Type A
07/16/2022
Section Cited
CCR
87303(a)
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87303(a) Maintenance and Operation-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 requirement is not met as evidenced by:
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Licensee agrees to repair the gate, air conditioning unit and water heater within 24 hours of this citation. Licensee agrees to read reg 87303 and provide memo of understanding to include a policy to ensure this will not occur again. Due to LPA Avila via e-mail within 24 hours.

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Based upon observation and interview the Licensee failed to keep the gate, air conditioning unit and water heater in good repair.

This poses an immediate Health, Safety and/or Personal Rights risk to residents in care.
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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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6