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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002773
Report Date: 05/09/2024
Date Signed: 05/09/2024 10:44:03 AM


Document Has Been Signed on 05/09/2024 10:44 AM - 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 OROVILLEFACILITY NUMBER:
045002773
ADMINISTRATOR:BINGHAM, DIANIAFACILITY TYPE:
740
ADDRESS:1900 20TH STTELEPHONE:
(530) 538-8200
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY:60CENSUS: DATE:
05/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jessica Owen -administrative assistantTIME COMPLETED:
10:45 AM
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05/09/2024 9:30 AM Licensing Program Analyst Rebecca Knight conducted an unannounced case management visit and met with Jessica Owen administrative assistant and explained the purpose of the visit. Today’s visit is regarding an incident that occurred on 04/29/2024 and was reported to licensing on 04/29/2024 by the facility.

It was reported that on 4/28/2024 Staff 1 (S1), Staff 2 (S2), Staff 3 (S3) went into Resident 2 (R2)’s room and found Resident 1 (R1) in the room. R1 to become agitated. R1 sat down at the foot of R2’s bed and then hit R2 on their feet. Report states S1 instructed S2 and S3 to restrain and remove R1 from the room. S2 placed their hands under R1’s arms and guided them out of the room. R1 became agitated. S1 stood in front of R2’s door preventing R1 from re-entering the room. R1 started yelling, screaming, and became combative. S1 called 911, Sheriff's Department responded and R1 was transported to Oroville Hospital and placed on a 5150 hold. Administrator in training contacted the psychiatrist on duty at Oroville Hospital. The psychiatrist made some medication changes, determined that a 5150 hold was not required, and released R1 back to the community. R1 was unable to remember any incident or recall the police incident. S1 was terminated as a result of the incident.

During the course of the investigation, it was learned that staff guided R1 out of R2’s room in a safe manner. Law enforcement did transport R1 to the hospital and R1 was released back to the facility with updated medications. R1 was not injured as a result of the incident. LPA is requesting that the facility update the resident’s care plan to address the behavior and submit the updated care plan to LPA. The facility has provided care staff with training on de-escalation techniques to keep all residents safe.

No deficiencies are being cited as a result of the investigation. Exit interview was conducted and the report was provided to COO Diania Bingham.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
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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