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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002773
Report Date: 08/01/2023
Date Signed: 08/01/2023 09:43:59 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/06/2023 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 59-AS-20230406102345
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: 31DATE:
08/01/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Michelle HernandezTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff failed to notify the authorized representative of a change in the resident’s health condition.
INVESTIGATION FINDINGS:
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On 08/01/23, Donna Gurriere and Jaynae Boyles, Licensing Program Analysts (LPAs) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 04/06/23. LPA Gurriere met with Michelle Hernandez, Assistant Administrator and explained the purpose of the visit.

Staff failed to notify the authorized representative of a change in the resident’s health condition.

During the interview process, the nurse, administrator, three staff persons and the resident (Resident 1) were interviewed. Various documents were obtained and reviewed to include Physicians Report, Admission Agreement, Resident Observation Log, Weight Chart, and the Veterans Affairs (VA) Health Care Report.

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: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
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 59-AS-20230406102345
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ROSELEAF OROVILLE
FACILITY NUMBER: 045002773
VISIT DATE: 08/01/2023
NARRATIVE
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continued

During the investigation process, it was stated that the resident lost 24 lbs during a four-month period while at the facility. It was reported by some staff that they thought that the resident’s authorized representative was notified; however, there was not any type of documentation that the administrator provided to indicate that the authorized representative was notified.

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 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. If any of the cited deficiencies are not corrected by the noted due date; civil penalties may be assessed.

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

DATE: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 59-AS-20230406102345
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ROSELEAF OROVILLE
FACILITY NUMBER: 045002773
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/02/2023
Section Cited
CCR
87468.1(8)
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Personal Rights - To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs.
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The administrator agrees to weekly inform the resident’s authorized representative of the resident’s ongoing condition. The administrator shall submit a copy of the initial document for review to the licensing agency.
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This requirement was not met as evidenced by: Based on interviews and document review, the licensee did not ensure that the resident’s authorized representatives were regularly informed of the resident’s change of condition.
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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: 08/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/06/2023 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 59-AS-20230406102345

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: 31DATE:
08/01/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Michelle HernandezTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Resident lost severe weight while in care.
Staff neglected resident in care.
Staff failed to meet the resident’s needs.
INVESTIGATION FINDINGS:
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On 08/01/23, Donna Gurriere and Jaynae Boyles, Licensing Program Analysts (LPAs) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 04/06/23. LPA Gurriere met with Michelle Hernandez, Assistant Administrator and explained the purpose of the visit.

Resident lost severe weight while in care.

During the interview process, the nurse, administrator, three staff persons and the resident (Resident 1) were interviewed. Various documents were obtained and reviewed to include Physicians Report, Admission Agreement, Resident Observation Log, Weight Chart, and the Veterans Affairs (VA) Health Care Report.

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: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
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 5
Control Number 59-AS-20230406102345
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ROSELEAF OROVILLE
FACILITY NUMBER: 045002773
VISIT DATE: 08/01/2023
NARRATIVE
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continued

During the investigation process, it was confirmed that the resident did loose a substantial amount of weight while residing at the facility; it is noted that the resident still resides at the facility. It was stated that the resident is on a mechanical diet and that his food is cut up into small bites, due to his swallowing issue.

All staff reported that the resident was and still is a healthy eater. It was stated that the resident has always ate well and that most times he has second helpings of food. It was indicated that although the resident was and is eating well, he may not have been absorbing nutrients. Although it can not be proven, sometimes when a resident has dementia and is not absorbing nutrients, it could be related to the term "Cachexia."

Staff neglected resident in care.
During the investigative process, it was alleged that the staff were not assisting the resident with feeding. Staff reported that they were available to assist the resident and were present during the mealtimes. Staff stated that there were times that the resident would ask for assistance with eating; however, they also reported that sometimes, the resident chose to eat on his own. Dated on 12/30/22 the resident's basic care services document states "Facility to provide moderate assistance with prompting during meals." The administrator advised that with the resident’s weight loss concern, she frequently goes into the dining room to ensure that the resident is eating or is being fed his meals.

Staff failed to meet the resident’s needs.
During the investigative process, all staff reported that the resident is on a mechanical diet to include soft foods and include small cut up pieces of food. Staff advised that the resident eats well and has a variety of foods that are provided. Staff stated that the resident eats his meals, and generally has two protein shakes a day. It was reported that the facility cooks are aware of and follow the resident’s special diet. It was logged in the resident's care log that he is eating at least two of his main meals, plus snacks, and protein shakes each day.

Although the above allegations mentioned may have happened, or are valid, there is not a preponderance of evidence to prove that the alleged violations 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: 08/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5