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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002773
Report Date: 04/23/2024
Date Signed: 04/23/2024 12:30:03 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, 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
02/06/2024 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 59-AS-20240206083319
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: 37DATE:
04/23/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Diania Bingham - COOTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff did not give paramedics the residents emergency paperwork - SUBSTANTIATED
INVESTIGATION FINDINGS:
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04/23/2024 10:00 AM 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 staff and reviewed the following documents: Admission agreement, Physicians report, hospital discharge papers for 1 resident.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
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-20240206083319
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: 04/23/2024
NARRATIVE
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Staff did not give paramedics the residents emergency paperwork - SUBSTANTIATED

It was reported that when paramedics were called to transport a resident from the facility to the hospital, the paramedic was told that facility staff did not have identifying information for the resident. This placed the resident in danger due to unknown code status, unknown health history and unknown drug allergies.

LPA reviewed Admission agreement for Resident 1 (R1) that shows and admission date to the facility of 01/10/2024. LPA also reviewed paperwork from hospital dated 02/04/2024 which states: Patient presents to the hospital from the assisted care facility and states that his name is R1. However we do not have a reliable birthday, social security number, or other identifying information. He is being admitted as a John Doe at this point. PAST MEDICAL HISTORY unable to obtain. Medical history is also unknown secondary to patient's severe dementia as well as any sort of specific identifying paperwork.

Staff interviews confirmed that staff normally have access to the resident’s emergency packet in a file cabinet and on the facility’s computer database. There was no record for R1 in the file cabinet and when staff attempted to access the record on the computer for R1 it was not in the system and they were unable to provide EMS with R1’s record as a result.

COO stated that all resident charts are downloaded into the facility’s system. When staff call 911 they click “Emergency Packet” and all documents that need to go to the hospital are right there. The resident’s packet should have been entered into the system within 24 hours of admission but the packet for this resident was not downloaded into the facility’s system. COO stated that the Resident Care Coordinator contacted the social worker at the hospital who confirmed they had all of the information within 1 hour.

It was determined that the emergency packet for Resident 1 was not available to be presented to EMS personnel as required. This allegation is substantiated.

Based on interviews and evidence obtained during the investigation, 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 LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of 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: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20240206083319
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: 04/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/07/2024
Section Cited
CCR
87506(a)
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87506(a) Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff. This requirement was not met as evidenced by:
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Licensee agrees to submit an updated process that ensures staff access to resident records immediately upon admission of a new resident. Additionally, licensee will conduct staff training on the new process which shall include the requirement to present EMS with resident records any time a resident is transported to hospital. Licensee shall submit staff sign in sheet as proof of correction.
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Based on interviews and document review it was determined that the paper file for R1 was not on file and the facility had not entered the resident’s record into their database where it could be accessed by facility staff. This resulted in staff not being able to provide EMS with the identifying records that are required by EMS in order to transport a resident to hospital. This poses a potential health and safety risk to residents in care.
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The proof of correction is to be received by LPA Knight by 05/07/2024.
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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: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 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
02/06/2024 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 59-AS-20240206083319

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:
04/23/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:TIME COMPLETED:
11:30 AM
ALLEGATION(S):
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3
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Staff are not trained properly on emergency procedures - UNSUBSTANTIATED
INVESTIGATION FINDINGS:
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04/23/2024 10:00 AM 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 staff and reviewed the following documents: Admission agreement, Physicians report, hospital discharge papers for 1 resident.

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
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-20240206083319
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: 04/23/2024
NARRATIVE
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Staff are not trained properly on emergency procedures - UNSUBSTANTIATED

It was reported that when paramedics were called to transport a resident from the facility to the hospital, the paramedic was told that facility staff did not have identifying information for the resident.

COO stated that staff are trained on the procedure to follow when EMS arrives at the facility to transport a resident.

It was determined that staff are trained on emergency procedures. This incident occurred due to staff not having access to R1’s records. This allegation is unsubstantiated.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5