045002773-6-18-2024-59-AS-KHOS-D6FVEQ-20240621162243

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045002773
Report Date: 06/18/2024
Date Signed: 06/18/2024 10:56:00 AM

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-20240206101159

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:	DATE:	06/18/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Jessica Owen - administrator in training		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not administer resident's medication – SUBSTANTIATED

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

06/18/2024 10:00 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Jessica Owen - administrator in training. COO Diania Bingham attended by telephone and gave permission for Ms. Owen to sign the report. The purpose of this visit was to deliver the results of a complaint investigation.

During the course of the investigation LPA interviewed the Executive Director, residents and staff. LPA reviewed the following documents: staff list with telephone numbers, Physician’s Report, admission agreement, for 2 residents. MAR, medication orders, medical records for 1 resident.

Continued on LIC9099-C

Substantiated

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: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

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 6

Control Number 59-AS-20240206101159

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: 06/18/2024

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
26
27
28
29
30
31
32

Staff did not administer resident's medication – SUBSTANTIATED

It was reported that a resident was hospitalized due to the facility not giving him his medication (Levothyroxine).

LPA document review: MAR dated November and December 2023 do not include the medication Levothyroxine.

Physician’s Reported dated 11/07/2023 includes the following information: SECONDARY DIAGNOSIS(ES): a. Treatment/medication (type and dosage)/equipment Hypothyroid, levothyroxine 17Smcg one PO dally.

COO stated That med was missed. On the original orders it does have levothyroxine, I don’t see it on the MARS.

It was determined that based on interviews and document review due to R1 not receiving his levothyroxine medication, his hyperthyroidism was untreated, and R1 was hospitalized and treated for severe hypothyroidism. This allegation is substantiated.

This is a repeat violation, the same violation was cited on 03/19/2024 and 04/23/2024. Civil penalties are being assessed in the amount of $1,000.00 this date on the attached LIC421M for repeat violation within a 12 month period.

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 Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 59-AS-20240206101159

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: 06/18/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/02/2024 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	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:	1 2 3 4 5 6 7	Licensee agrees to conduct a medication training for all staff exclusive to the requirement of ensuring that residents have all required medications upon admission to the facility and will provide LPA with training subject matter and sign in sheet with dates and staff signatures.
	8 9 10 11 12 13 14	Based on interviews and document review it was determined that due to R1 not receiving his levothyroxine medication, his hyperthyroidism was untreated, and R1 was hospitalized and treated for severe hypothyroidism. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Civil penalties are being asessed in the amount of $1,000.00 for repeat violaton within a 12 month period. The proof of correction is to be received by LPA Knight by 07/02/2024.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 6

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-20240206101159

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:	DATE:	06/18/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Diania Bingham - COO		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not feeding resident - UNSUBSTANTIATED
Staff did not properly care for resident's wounds - UNSUBSTANTIATED
Staff are not meeting resident's laundry needs - UNSUBSTANTIATED
Staff are not providing a comfortable temperature for residents - UNSUBSTANTIATED

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Staff are not feeding resident -UNSUBSTANTIATED

It was reported that the facility was not feeding a resident.
All staff that were interviewed stated that R1 ate all of his meals.
COO stated I know he was eating really well and adjusting really well to us.
It was determined that that facility has been providing meal to R1 and R1 was eating his meals. This allegation is unsubstantiated.

Contnued ion 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: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

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 6

Control Number 59-AS-20240206101159

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: 06/18/2024

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
26
27
28
29
30
31
32

Staff did not properly care for resident's wounds - UNSUBSTANTIATED

It was reported that a resident had cuts on their body that were not being treated.

Staff stated that R1 had some skin tears and bruises when he moved in, the med techs would bandage him if he was bleeding but “outside people” were providing wound care.

COO stated When he got here from his previous facility, he had existing skin tears that he would pick at and they would reopen that’s what kept him chronic. He had skin tears on his legs and we sent him out to have them look at them and they sent him back to us. The VA was following the wounds on his legs. They kept his skin tears wrapped because he picks at them and doesn’t allow them to heal. The VA does it all, even if it (bandages) comes loose the VA comes in.

It was determined that when R1 moved into the facility in January 2024 he had some bruises and skin tears. The VA was providing care for these wounds although the med tech would provide first aid if required. This allegation is unsubstantiated.

Staff are not meeting resident's laundry needs - UNSUBSTANTIATED

It was reported that a resident had no clean clothes.

Staff stated that R1 was showered twice a week and his laundry was done on the same days. Staff always assisted R1 with changing clothes. When R1 moved into the facility he had a lot of shirts, underwear, and jeans but not a lot of pajama bottoms.

COO stated that staff have been doing the resident’s laundry. They would encourage him to change his clothes. He was very self-determined and he would self-direct but staff would try to get him to change his clothes.

It was determined that when R1 moved into the facility he had a lot of shirts, underwear, and jeans but not a lot of pajama bottoms. Staff were doing R1’s laundry twice a week. This allegation is unsubstantiated.

Continued on LIC9099-C

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 59-AS-20240206101159

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: 06/18/2024

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
26
27
28
29
30
31
32

Staff are not providing a comfortable temperature for residents - UNSUBSTANTIATED

LPA observed the thermostats to all be set at 78 degrees Fahrenheit.

Staff interviews revealed that the temperature can vary but overall, the facility is kept at a comfortable temperature.

COO stated the thermostat is set at 78 degrees all of them are in controlled environments.

It was determined the thermostats are all set for 78 degrees which is a comfortable temperature. This allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED.

An exit interview was conducted. 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: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 6