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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 12:46:24 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
04/09/2024 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 59-AS-20240409125620
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:
12:00 PM
MET WITH:Diania Bingham - COOTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility is not dispensing medication as prescribed by physician – SUBSTANTIATED
INVESTIGATION FINDINGS:
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04/23/2024 10:30 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 3 staff. LPA reviewed the following documents: Medication Administration Record, Physicians Report, care plan, admission agreement 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 4
Control Number 59-AS-20240409125620
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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Page 2

Facility is not dispensing medication as prescribed by physician – SUBSTANTIATED

LPA reviewed admission agreement that shows that Resident 1 (R1) moved into the facility on 2/13/2024.

LPA reviewed Medication Administration Record (MAR) for R1 dated March 3, 2024 through March 30, 2024. The MAR reflects that during this time period R1 missed all doses of the following medications on the following dates:

Divaloprex Sodium Oral Tablet Delayed Release 250 mg: Start date 02/13/2024. Not dispensed 03/03/2023 through 03/20/2024.

Donepezil HCI Oral Tablet 10 MG Start date 1/27/2024. Not dispensed 03/03/2023 through 03/20/2024.

Escitalopram Oral Tablet 5mg: Start date 2/14/2024. Not dispensed 03/04/2023 through 03/20/2024.

Furosemide 20 mg: Start date 2/13/2024. Not dispensed 03/02/2023 through 03/20/2024.

Melatonin Oral Tablet 3 MG: Start date 3/15/2024. Not dispensed 03/15/2023 through 03/22/2024 2024.

Multiple Vitamin oral tablet: Start date 3/5/2024. Not dispensed 3/16/2024 through 03/31/2024.

Polythylene Glycol 3350 ORAL Powder: Start date 3/15/2024. Not dispensed 3/16/2024 through 3/31/2024.

Continued on LIC9099-C pg 3

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 4
Control Number 59-AS-20240409125620
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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Page 3
Quetiapine Fumarate Oral Tablet 25 MG: Start date 2/14/2024. Not dispensed 03/07/2024 through 03/20/2024.

Spironolactone Oral Tablet 25 MG: Start date 2/14/2024. Not dispensed 3/02/2024 through 3/20/2024.

Vitamin D (Cholecalciferol) Oral capsule 50 MCG: Start date 3/15/2024. Not dispensed 3/16/2024 through 3/28/2024.

Ferrous Sulfate Oral Tablet 325 (65 Fe) MG: Start date 03/15/2024. Not dispensed 3/16/2024 through 3/28/2024.

All of the aforementioned medications have exception reasons noted in the MAR that say “Not on Hand”, or Waiting on Pharmacy.”

Staff interviews revealed that R1 ran out of multiple medications.

It was determined that the facility did not ensure that R1 was dispensed their medications as prescribed by their physician due to R1 running out of multiple medications. This allegation is substantiated.

Upon inspection of the facility’s compliance history, LPA determined that the licensee was issued a deficiency for the same violation within the past 12 months. As a result, a civil penalty was assessed in the amount of $250.00 on 04/23/2024 on the attached LIC421.

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: 3 of 4
Control Number 59-AS-20240409125620
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 A
05/07/2024
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Licensee agrees to conduct a medication training for all med techs concerning the requirement to ensure that residents do not run out of their medications and will provide LPA with training subject matter and sign in sheet with dates and staff signatures. In addition, licensee shall submit a plan to LPA that outlines the process that all med techs must follow to ensure that residents do not run out of medications.
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Based on interviews and document review it was determined that R1 ran out of multiple medications for a period ranging from 8 to 18 days. This poses an immediate 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: 4 of 4