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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002773
Report Date: 12/18/2025
Date Signed: 12/18/2025 12:46:08 PM

Unsubstantiated


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
10/20/2025 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 59-AS-20251020142705
FACILITY NAME:ROSELEAF OROVILLEFACILITY NUMBER:
045002773
ADMINISTRATOR:BAXTER, STACEYFACILITY TYPE:
740
ADDRESS:1900 20TH STTELEPHONE:
(530) 538-8200
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY:60CENSUS: DATE:
12/18/2025
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Stacey Baxter - executive directorTIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Staff did not allow resident to seek medical attention.- UNSUBSTANTIATED
Licensee does not ensure staff are receive adequate training. - UNSUBSTANTIATED
Facility is not following a resident’s care plan. - UNSUBSTANTIATED
INVESTIGATION FINDINGS:
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12/18/2025 12:15 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to deliver the results of a complaint investigation. LPA met with administrator Stacey Baxter and explained the purpose of the visit.

During the course of the investigation LPA toured the facility, conducted interviews and reviewed documents.
Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
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 59-AS-20251020142705
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: 12/18/2025
NARRATIVE
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Page 2

Staff did not allow resident to seek medical attention. - UNSUBSTANTIATED

It was reported that a resident who was not feeling well wanted to go to the hospital and staff did not arrange for the resident to go to the hospital.

LPA reviewed care plan for Resident 1 (R1) which states that R1 is on hospice. The care plan states the supervisor will contact the hospice RN manager and the responsible party as needed. In case of emergencies not related to hospice care (e.g., severe bleeding or injury), staff are to call 911, notify hospice, and inform the responsible party. The Emergency Protocol states that staff will contact hospice for any issues related to the resident’s hospice care.

ED stated Resident 1 (R1) is on hospice and the hospice nurse would be called if R1 was not feeling well. Any time the facility has tried to send R1 out to the hospital they have refused to go.

This allegation is unsubstantiated.

Licensee does not ensure staff are receive adequate training.- UNSUBSTANTIATED

It was reported staff are not properly trained in how to assist a resident with a transfer from a wheelchair to the bed

LPA reviewed the “New Hire Training Check-Off Sheet” which documents the initial training topics that all new hires undergo when they start working at the facility. Topics include Mobility & Safe Transfers and Bending and Lifting Techniques.

ED stated new staff have 20 hours of video training before they start working with residents and they get an additional 20 hours hands on training and shadowing. This training is documented.

This allegation is unsubstantiated.

Continued on LIC9099-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20251020142705
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: 12/18/2025
NARRATIVE
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Page 3

Facility is not following a resident’s care plan. - UNSUBSTANTIATED

It was reported staff do not maintain record of resident’s bowel movements.

LPA reviewed care tracking sheets for two residents for the month of October 2025. The tracking sheets document bowel movements on all days of the month for all shifts. Both tracking sheets are filled out correctly for both residents.

ED stated this is part of each resident’s care plan and staff chart it daily

This allegation is unsubstantiated.

This agency has investigated the above allegations. 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. No deficiencies cited. Exit interview conducted and a copy of the report was provided to administrator Stacey Baxter.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3