045002775-1-28-2021-25-AS-JAVA-BXPP3U-20210128095808

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 045002775
Report Date: 01/27/2021
Date Signed: 01/28/2021 10:00:51 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

FACILITY NAME:	ROSELEAF GARDENS		FACILITY NUMBER:	045002775
ADMINISTRATOR:	TRISEL, DARREN		FACILITY TYPE:	740
ADDRESS:	2770 SIERRA LADERA		TELEPHONE:	(559) 970-1240
CITY:	CHICO	STATE: CA	ZIP CODE:	95928
CAPACITY:	56	CENSUS: 26	DATE:	01/27/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:06 AM
MET WITH:	Administrator Eric Perry		TIME COMPLETED:	01:30 PM

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	Licensing Program Analyst (LPA) Jaclyn Avila conducted a Pre-Licensing inspection of the facility via Facetime due to COVID 19 precautions. LPA Avila met with Administrator Eric Perry. The building consists of 1 kitchen, 32 resident bedrooms, 16 bathroom(s), 4 dining rooms, 7 living room, 8 laundry room. The facility has requested licensure for a capacity of 56 residents ( 56 non-ambulatory, 0 bedridden, 8 hospice). Currently there are 26 residents in the facility. LPA Avila toured the facility with the administrator. The physical plant is consistent with the submitted facility sketch/floor plan. The facility is clean and in good repair. The facility temperature is between 72 degrees and 75 degrees. All window screens are clean and in good repair. There is appropriate lighting in the facility and in each room. There is a locked centralized storage area for resident medications. Protective devices are in use such as nonslip material on rugs. Indoor and outdoor passageways and stairways are free of obstruction. Stairways, inclines, ramps, open porches, and areas of potential hazard accessible to residents are well-lit and equipped with sturdy hand railings. Disinfectants, cleaning solutions, poisons, and other items which could pose a danger are inaccessible. Fire alarms and smoke alarms operate properly. Carbon monoxide detectors operate properly. Resident bedrooms are large enough to allow for easy passage between and comfortable usage of beds and other required items of furniture, and any resident assistant devices such as wheelchairs or walkers. There is a bed for each resident equipped with good springs, clean and comfortable mattress, pillow(s), and bedding. There is a chair, night stand, chest of drawers, and lamp or sufficient lighting for each resident.

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: ROSELEAF GARDENS	FACILITY NUMBER: 045002775
	VISIT DATE: 01/27/2021

NARRATIVE

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Bathroom floors are clean, sanitary, and odorless. The hot water temperature is between 105-120 degrees Fahrenheit. All bathtubs, showers, and toilets have grab bars. All bathtubs and showers have non-skid mats or strips. All bathtubs, showers, toilets, and sinks operate properly. There is at least one (1) toilet and sink for each six (6) persons, which includes residents, family and personnel.

Nightlights are present in hallways outside non-private bathrooms. There is a sufficient supply of hygiene items such as soap and toilet paper. There is a sufficient supply of clean linen, including blankets, bedspreads, top sheets, bottom sheets, pillow cases, mattress pads, bath towels, hand towels, and wash cloths.

Kitchen and dining room floors are clean. There are no pesticides, poisons, or other toxic substances stored in any food storage or preparation area or with utensils. Cleaning supplies are kept in areas separate from food supplies. Freezer is -4 degrees Fahrenheit. The refrigerator is 38 degrees Fahrenheit. A seven (7) day supply of non-perishable food is present. There are sufficient amounts of equipment for the storage, preparation, and service of food.

There is confidential storage of personnel records at the facility. There is confidential storage of resident records at the facility.

Emergency exiting plans and telephone numbers are posted. Facility Theft and Loss Program is posted. The Licensing Complaint Poster will be posted. Resident Personal Rights are posted. Posting Title 22, Section 87468 and Health and Safety Code, Section 1569.269 meets this requirement. Resident Council Rights are posted. Posting a copy of the Rights of Resident Councils PUB 747 meets this requirement.

There is a first aid kit, including sterile dressings, bandages, thermometer, scissors, tweezers, and a current first aid manual. There are laundry supplies and equipment, including at least one machine in good repair.

Cont'd on LIC 809-C

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2021

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: ROSELEAF GARDENS	FACILITY NUMBER: 045002775
	VISIT DATE: 01/27/2021

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There is an operating telephone available to residents. Emergency lighting supplies e.g., flashlights, batteries are present. Vehicles used to transport residents are in safe operating condition.

DEMENTIA CARE
Knives, matches, tools and other items that could constitute a danger are inaccessible. Over the counter medications, nutritional supplements or vitamins, alcohol, and cigarettes are inaccessible. Toxic substances such as certain plants, gardening supplies, cleaning supplies, and disinfectants are inaccessible. Outdoor activity space is completely enclosed by a fence with self-closing latches and gates, or walls. Auditory devices are in place to monitor exits, if exiting presents a hazard to any resident.

For facilities of 16 or more capacity Regulation 87303:

(i) Facilities shall have signal systems which shall meet the following criteria:

(1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:

(A) Operate from each resident's living unit.

(B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff.

(C) Identify the specific resident living unit.

(2) Facilities having more than one wing, floor or building shall be permitted to have a separate system in each, provided each meets the above criteria.

At time of visit facility’s signal system was not in compliance. Administrator is currently ensuring the signal system will operate from each resident's living unit and will have this completed by COB on 1/28/21.

No citations issues during today’s tele-visit.

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2021

LIC809 (FAS) - (06/04)

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