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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002773
Report Date: 11/14/2024
Date Signed: 11/19/2024 11:01:04 AM

Document Has Been Signed on 11/19/2024 11:01 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/
DIRECTOR:		BAXTER, STACEYFACILITY TYPE:
740
ADDRESS:1900 20TH STTELEPHONE:
(530) 538-8200
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY: 60CENSUS: 35DATE:
11/14/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Stacey Baxter - administratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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11/14/2024 01:00 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced and met with administrator Stacey Baxter. The purpose of the visit was to conduct an unannounced case management visit to deliver / confirm orders to individual for immediate exclusion from all facilities. The staff in question is associated to the facility but administrator confirmed the staff is not employed by the facility currently.

LPA Knight served order of immediate exclusion effective 11/14/2024 and explained the "Immediate Exclusion" notice indicating that staff member (S1) cannot be allowed to work, be present, and/or live in a CCL licensed facility, or have contact with clients in any residential facility or child day care licensed by the California Department of Social Services. Therefore, the Department orders the facility to ensure that S1 is not physically present in the facility. Administrator indicated they understood the notice and confirmed that S1 is currently not working at the facility.

Exit interview completed. Copy of report was provided to administrator Stacey Baxter. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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