045002773-3-19-2024-59-AS-RKNT-D3HTES-20240319144024

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 045002773
Report Date: 03/19/2024
Date Signed: 03/19/2024 02:41:19 PM

Document Has Been Signed on 03/19/2024 02:41 PM - 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

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: 36	DATE:	03/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Stacey Baxter - administrator		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	03/19/2024 10:30 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with administrator Stacey Baxter and explained the purpose of the visit. COO Diania Bingham was also present for the inspection. LPA Knight and the administrator toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and facility grounds. Staff and resident files were reviewed. All employees requiring background checks are cleared. Medications were reviewed. There is a schedule of recreational activities planned for the residents. Bedding, linens, and towels for residents were observed and found to be clean and in good repair. There is an adequate supply of toiletries for the residents. Medication is locked in a locked cabinet in a locked room. The facility was observed to be at a comfortable temperature. Hot water measured between 105 – 120 degrees F. Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. The facility has a second building that contains 3 resident rooms but is not occupied presently. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and inspected. Smoke detectors are all operational and are inspected annually by fire marshall and monitored by Foothill Fire Protection continually. There are no pools/bodies of water are on premises. Disaster drills are conducted every six months, the facility has been conducting fire drills every 3 months. Continued on LIC809-C

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/19/2024

NARRATIVE

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LPA reviewed 6 staff files. 4 of 6 staff files had expired first aid training certificates.

LPA observed the following during the tour of the facility: East side covered patio: wooden desk, med cart, commode. Back patio next to storage shed: broken patio table. West side of building: twin mattress on patio. Rear of building, south side: 2 window screens laying on the ground. Gutter above south side patio had weeds growing. Refrigerator in kitchen in dining room needs to be defrosted. Medication room: Window screen missing from window.

Deficiencies are being cited as a result of today’s inspection and are included on the attached LIC9099-D forms.

Exit interview conducted and copy of report was provided to administrator Stacey Baxter.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/19/2024 02:41 PM - 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ROSELEAF OROVILLE	FACILITY NUMBER: 045002773
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/02/2024
	Plan of Correction
1 2 3 4	LIcensee agrees to remove and dispose of all named debris, defrost refrigerator, clean gutters, and replace window screens. Licensee shall submit photographs to LPA as proof of correction.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 03/19/2024 02:41 PM - 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ROSELEAF OROVILLE	FACILITY NUMBER: 045002773
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 of 6 staff files which pose a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/02/2024
	Plan of Correction
1 2 3 4

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC809 (FAS) - (06/04)

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