045002773-3-7-2022-25-AS-LMUZ-CDFRHS-20220413130249

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045002773
Report Date: 03/07/2022
Date Signed: 03/07/2022 09:43:07 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/25/2021 and conducted by Evaluator Dawn Keane

COMPLAINT CONTROL NUMBER: 25-AS-20210825130006

FACILITY NAME:	ROSELEAF OROVILLE		FACILITY NUMBER:	045002773
ADMINISTRATOR:	BROWN, TERRY L		FACILITY TYPE:	740
ADDRESS:	1900 20TH ST		TELEPHONE:	(559) 970-1240
CITY:	OROVILLE	STATE: CA	ZIP CODE:	95965
CAPACITY:	60	CENSUS: 29	DATE:	03/07/2022
		UNANNOUNCED	TIME BEGAN:	09:19 AM
MET WITH:	Terry Brown, Administrator		TIME COMPLETED:	11:00 PM

ALLEGATION(S):

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Staff are not appropriately wearing masks.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Dawn Keane conducted an unannounced complaint investigation visit regarding the above mention allegation: Staff are not appropriately wearing masks. LPA met with Administrator (AD) Terry Brown and informed AD of the reason for the visit. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA contacted facility and completed a facility risk assessment.
LPA ensured they applied hand sanitizer before entering he facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. Additionally, LPA was screened at the front door.

Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Dawn Keane	TELEPHONE: (530) 895-2660
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2022

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 3

Control Number 25-AS-20210825130006

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ROSELEAF OROVILLE	FACILITY NUMBER: 045002773
	VISIT DATE: 03/07/2022

NARRATIVE

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During the investigation it was determined that there was sufficient evidence to Substantiate that facility staff were not wearing masks appropriately. LPA's Keane and Valencia entered the facility on 8/27/21 at 12:30 p.m. and waited for approximately (5) five minutes for an employee to screen them. After about (5) five minutes, LPA's screened themselves. While LPA's were screening they observed an office with an open door and (2) two people sitting at a desk. One person was wearing a mask and the other, identified by AD as the Human Resources person was wearing a mask under her nose. LPA's toured the facility with AD, where LPA's observed another office with an open door and a person sitting behind the desk with a mask under her chin. LPA's went to AD's office after touring the facility and AD admitted that staff do not wear masks appropriately and need constant reminders about this issue.

LPA received the LIC 808 (Mitigation Plan) from AD on 5/24/2021. LPA reviewed the LIC 808 and on page 13, the mitigation plan it states; "All facility staff are wearing a face covering while on the premises." Facility is not following the mitigation plan that was submitted to Licensing.

Based on the evidence obtained, the preponderance of evidence standard has been met; therefore , the allegation is found to be Substantiated. California code of Regulations (Title 22) is being cited on the attached LIC 9099D. Appeal rights were provided and exit interview conducted.

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Dawn Keane	TELEPHONE: (530) 895-2660
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20210825130006

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ROSELEAF OROVILLE	FACILITY NUMBER: 045002773
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/16/2022 Section Cited CCR 87470(c)(1)(F)	1 2 3 4 5 6 7	87470(c)(1)(F) Infection Control Requirements: An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. The Infection Control Plan shall include all of the following:	1 2 3 4 5 6 7	AD agrees to develop a plan that includes the importance of staff wearing masks at all times when in the facility. The AD shall submit the POC to the licensing agency within 24 hours.
	8 9 10 11 12 13 14	Staff shall demonstrate knowledge of and skill in infection control... This requirement has not been met as evidenced by: LPA's interviews and observations. Staff did not follow infection control requirements as required. This poses an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14
	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: Rayna L Bryson	TELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Dawn Keane	TELEPHONE: (530) 895-2660
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3