045002773-3-7-2024-59-AS-KHOS-D39KMC-20240311080120

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045002773
Report Date: 03/07/2024
Date Signed: 03/07/2024 01:57:41 PM

Unsubstantiated

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
01/31/2024 and conducted by Evaluator Rebecca Knight

COMPLAINT CONTROL NUMBER: 59-AS-20240131143054

FACILITY NAME:	ROSELEAF OROVILLE		FACILITY NUMBER:	045002773
ADMINISTRATOR:	BINGHAM, DIANIA		FACILITY TYPE:	740
ADDRESS:	1900 20TH ST		TELEPHONE:	(530) 538-8200
CITY:	OROVILLE	STATE: CA	ZIP CODE:	95965
CAPACITY:	60	CENSUS: 35	DATE:	03/07/2024
		UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Diania Bingham - COO		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility failed to provide documents to responsible party. - UNSUBSTANTIATED

INVESTIGATION FINDINGS:

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03/07/2024 12:55 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with COO Diania Bingham. The purpose of this visit was to deliver the results of a complaint investigation.

During the course of the investigation LPA interviewed the COO and reviewed the following documents: Identification and Emergency Information, Physician’s Report, Durable Power of Attorney for Health Care, Admission Agreement, Release of Client/Resident Medical Information, Authorization for Disclosure of Health Information for 1 resident, certified mail receipt for package delivery.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240131143054

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: 03/07/2024

NARRATIVE

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Facility failed to provide documents to responsible party - UNSUBSTANTIATED

It was reported that the POA has made multiple verbal and one written request for the resident’s file and did not receive the record.

LPA reviewed LIC601 Identification and Emergency Information for Resident 1 (R1) which listed R1’s husband as the person responsible for financial affairs, payment for care, Legal Guardian. LPA reviewed Resident 1’s Admission Agreement which lists R1’s daughter as the responsible person. LPA reviewed R1’s Durable Power of Attorney for Health Care which designated R1’s husband and three other family members. LPA also reviewed certified mail reciept for package delivery.

COO stated they asked the family member to put the request in writing because the facility needed to include the written records request in the resident’s chart. COO stated they had not received a written request.

LPA advised the responsible person (RP) to send an email directly to the COO to request the record and provided the COO’s email address to the RP. COO stated they mailed R1’s record to the address on file, certified mail receipt confirms this statement.

LPA was notified by complainant that a large packet including the resident record was received by the responsible party that included intake paperwork, and an assessment. Complainant was expecting to receive any records that contained medical or financial information for the resident. LPA explained to complainant that the facility does not have medical records and advised complainant to contact R1’s medical provider to obtain those records.

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.

Exit interview conducted and a copy of the report was provided to COO Diania Bingham.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC9099 (FAS) - (06/04)

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