045002773-5-20-2022-25-AS-RKNT-CELRW8-20220520132242

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 045002773
Report Date: 05/20/2022
Date Signed: 05/20/2022 01:23:07 PM

Document Has Been Signed on 05/20/2022 01:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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
ADMINISTRATOR:	BROWN, TERRY L		FACILITY TYPE:	740
ADDRESS:	1900 20TH ST		TELEPHONE:	(530) 538-8200
CITY:	OROVILLE	STATE: CA	ZIP CODE:	95965
CAPACITY:	60	CENSUS: 36	DATE:	05/20/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Amber Farmer - Resident care coordinator		TIME COMPLETED:	02:00 PM

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05/20/2022 1:30 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Amber Farmer - Resident care coordinator, and Lisa Sapp, Sales Director. The purpose of this visit was to conduct a case management investigation. Prior to initiating 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; contacted administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 Mask, gloves.

Today's meeting concerns an investigation into an incident report that was received from the facility on 05/10/2022 regarding an incident that occurred at the facility on 05/09/2022. It was reported that on 05/09/2022 Resident 1 (R1) was playing the piano and Resident 2 (R2) asked R1 to stop playing the piano. R1 yelled at R2 and R2 became upset and pushed R1 down. R1 hit their wrist causing a gash in their skin. 911 was called and R1 was transported to the local ER where R1 was treated for a right forearm laceration. R1 received stitches as a result of the injury and was released back to the facility the same day.

It was learned that R1 has dementia and R2 has cognitive decline. R1's stitches were removed on 5/16/22 and the wound has healed. R2 is new to the facility, it was their first week at the facility. R1 is very vocal but has never had a conflict with another resident.

In order to prevent this from happening again the facility held a care conference with R2’s family and explained the situation. It was explained this is inappropriate behavior. They suggested that R2 speak with administration or care staff and tell them when they are upset and staff will help to solve the problem. R2 was very apologetic and remorseful and apologized to R1 and staff.

No deficiencies cited. Exit interview conducted and a copy of the report was emailed to Amber Farmer - Resident care coordinator.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

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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