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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002773
Report Date: 05/30/2023
Date Signed: 05/30/2023 01:15:25 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/21/2023 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 25-AS-20230221133336
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: DATE:
05/30/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:AMBER FARMERTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility staff are not properly addressing an insect infestation in the facility.
INVESTIGATION FINDINGS:
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Donna Gurriere, Licensing Program Analyst was in contact and met with Amber Farmer, Administrator.

Facility staff are not properly addressing an insect infestation in the facility.

During the interview process, the administrator, six staff persons, and a regional center staff person were interviewed. Various documents were obtained and reviewed to include Physicians Reports, Admission Agreements, Appraisal and Needs, Medication Logs, regional center reports, nurse practitioner’s notes, staff telephone numbers and staff training documents.



continued
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
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 8
Control Number 25-AS-20230221133336
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 05/30/2023
NARRATIVE
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During the investigation process, it was reported by nearly all staff that currently the facility has an insect and mice infestation. It was stated that mice are seen in resident rooms, hallways, the dining room, and maintenance room. It was reported that cockroaches have been seen throughout the facility and especially in the upper kitchen area. The administrator reported that the facility is using Orkin Pest Control in an effort to eliminate the cockroaches and mice; however, it does not appear to be having an effect.

Serious health issues can arise with residents in care due to disease carrying roaches and mice. The administrator shall seek an alternative method to eradicate roaches and mice. LPA Gurriere and the administrator will discuss alternative methods.

Based on investigation 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), is being cited on the attached LIC 9099D.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 25-AS-20230221133336
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/31/2023
Section Cited
CCR
87303(a)
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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.
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The administrator agrees to seek alternative methods to eradicate roaches and mice.
Administrator agrees to seek another pest control company in an effort to eliminate the rodents.

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This requirement was not met as evidenced by: Based on documentation and interviews, the licensee did not ensure that the facility was clean, safe and sanitary. This poses an immediate health and safety 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: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/21/2023 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 25-AS-20230221133336

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: DATE:
05/30/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:AMBER FARMERTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Resident developed a stage 4 pressure injury due to neglect by staff.
Facility staff did not assist a resident with feeding.
Facility staff did not assist a resident with toileting needs resulting in the resident developing severe rashes.
Facility staff did not seek timely medical attention for residents’ pressure injuries.
Facility staff are not repositioning a resident.
Facility staff speak inappropriately to residents.
Facility staff leave a wheelchair bound resident in his room facing the bed for hours each day.
INVESTIGATION FINDINGS:
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Donna Gurriere, Licensing Program Analyst was in contact and met with Amber Farmer, Administrator.

During the interview process, the administrator, six staff persons, and a regional center staff person were interviewed. Various documents were obtained and reviewed to include Physicians Reports, Admission Agreements, Appraisal and Needs, Medication Logs, regional center reports, nurse practitioner’s notes, staff telephone numbers and staff training documents.

Resident developed a stage 4 pressure injury due to neglect by staff.

During the interview process, the administrator, six staff persons, and a regional center staff person were interviewed. Various documents were obtained and reviewed to include Physicians Reports, Admission Agreements, Appraisal and Needs, Medication Logs, regional center reports, nurse practitioner’s notes, staff telephone numbers and staff training documents.

continued
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
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 8
Control Number 25-AS-20230221133336
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 05/30/2023
NARRATIVE
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During the investigation process, the hospice notes for the resident (Resident 1) were reviewed. The notes did indicate that the resident did develop a pressure injury during the last days of life. The resident was receiving services from the hospice nurse; however, it could not be proven that the resident had a stage 4 pressure injury.

It was reported that a second resident (Resident 2) also had a pressure injury. On 02/06/23, hospital notes indicated that the resident had a pressure injury on his coccyx. The notes did not indicate that the pressure injury was at a stage 4. It was reported that the resident had a stage 1 and that staff were putting cream on the injury.

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.



Facility staff did not assist a resident with feeding.

During the interview process, the administrator, six staff persons, and a regional center staff person were interviewed. Various documents were obtained and reviewed to include Physicians Reports, Admission Agreements, Appraisal and Needs, Medication Logs, regional center reports, nurse practitioner’s notes, staff telephone numbers and staff training documents.

During the investigation process, it was reported that a resident (Resident 2) had difficulty in feeding himself due to his diagnosis. It was stated that the resident was difficult, would sometimes throw his food, wanted to be independent and often times the resident would refuse to accept assistance. It was reported that the facility was short staffed; however, overall, staff reported that they assisted the resident with feeding.

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: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 8
Control Number 25-AS-20230221133336
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 05/30/2023
NARRATIVE
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Facility staff did not assist a resident with toileting needs resulting in the resident developing severe rashes.

During the interview process, the administrator, six staff persons, one resident, the nurse consultant and a regional center staff person were interviewed. Various documents were obtained and reviewed to include Physicians Reports, Admission Agreements, Appraisal and Needs, Medication Logs, regional center reports, nurse practitioner’s notes, staff telephone numbers and staff training documents.

During the investigation process, it was reported that a resident (Resident 2) had developed a rash in his groin area. It was stated by most staff that all residents in the facility are checked for incontinence issues and if needed, are changed every two hours. In addition, it was reported that the resident is capable of advising staff when he needs to be changed. A report from the nurse practitioner was reviewed and he prescribed and ordered a type of barrier cream for staff to apply to the resident’s rash. On 03/06/23, LPA Gurriere met with Resident 2 and asked if he had recently been changed. The resident and his caregiver both confirmed that he had already been changed that morning.

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.

Facility staff did not seek timely medical attention for residents’ pressure injuries.

During the interview process, the administrator, six staff persons, and a regional center staff person were interviewed. Various documents were obtained and reviewed to include Physicians Reports, Admission Agreements, Appraisal and Needs, Medication Logs, regional center reports, nurse practitioner’s notes, staff telephone numbers and staff training documents.


continued
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 25-AS-20230221133336
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 05/30/2023
NARRATIVE
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It was reported that Resident 1 did have a pressure injury that he developed towards the end of life and that he was receiving hospice services support. It was stated that Resident 2 had a pressure injury and that it was staged at a stage 1. During the investigation process, the administrator ensured that Resident 2 was receiving home health services to address his pressure injury. Residents did receive medical attention for their pressure injuries.

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.

Facility staff are not repositioning a resident

During the interview process, the administrator, six staff persons, one resident, and a regional center staff person were interviewed. Various documents were obtained and reviewed to include Physicians Reports, Admission Agreements, Appraisal and Needs, Medication Logs, regional center reports, nurse practitioner’s notes, staff telephone numbers and staff training documents.

During the investigative process staff were interviewed and they reported that they repositioned the resident generally every two hours. It was reported that many times the resident would just roll back into his same position which placed the resident on his backside. On 03/06/23 LPA Gurriere met with the resident and observed that the resident could reposition himself in bed, as needed.

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.


continued
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 25-AS-20230221133336
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 05/30/2023
NARRATIVE
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Facility staff speak inappropriately to residents.

During the interview process, the administrator, six staff persons, and a regional center staff person were interviewed. Various documents were obtained and reviewed to include Physicians Reports, Admission Agreements, Appraisal and Needs, Medication Logs, regional center reports, nurse practitioner’s notes, staff telephone numbers and staff training documents.

During the investigative process, staff were interviewed, and some staff reported that a staff person did speak inappropriately to the residents. However, overall, it was stated by staff that they did not hear the staff person speak inappropriately to the residents. The staff person in question stated that he “quit the job," due to his own personal issues.

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.

Facility staff leave a wheelchair bound resident in his room facing the bed for hours each day.

During the interview process, the administrator, six staff persons, a resident and a regional center staff person were interviewed. Various documents were obtained and reviewed to include Physicians Reports, Admission Agreements, Appraisal and Needs, Medication Logs, regional center reports, nurse practitioner’s notes, staff telephone numbers and staff training documents.

During the investigative process staff were interviewed and some staff reported that a staff person left the resident in his room facing the bed; however, overall, it was stated by staff that they were unaware of the incident. In addition, the resident was observed sitting in his bed and interacting with a staff person.

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: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 8