045002775-1-29-2024-59-AS-KHOS-D32H4Z-20240304045245

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045002775
Report Date: 01/29/2024
Date Signed: 01/29/2024 03:40:57 PM

Substantiated

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
12/11/2023 and conducted by Evaluator Jaynae Boyles

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20231211084559

FACILITY NAME:	ROSELEAF GARDENS		FACILITY NUMBER:	045002775
ADMINISTRATOR:	BINGHAM, DIANIA		FACILITY TYPE:	740
ADDRESS:	2770 SIERRA LADERA		TELEPHONE:	(530) 895-0800
CITY:	CHICO	STATE: CA	ZIP CODE:	95928
CAPACITY:	56	CENSUS: 37	DATE:	01/29/2024
		UNANNOUNCED	TIME BEGAN:	01:53 PM
MET WITH:	Resident Care Corrdintator-Don Daniels		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff are not meeting resident's needs

INVESTIGATION FINDINGS:

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01/29/2024 Licensing Program Analyst (LPA) Jaynae Boyles made an unannounced visit to the facility and met with Resident Care Corrdinator, Don Daniels. The purpose of this visit is to deliver the results of a complaint investigation.
During the interview process, the Administrator, five staff members and witnesses were interviewed. During the review of records, LPA reviewed the files of one resident, including incident reports, medical records, admissions agreement.
LPA investigated the allegation, “Staff are not meeting resident's needs.” During the investigation, the Administrator reported that the resident (R1) was outside for an unknown amount of time between 11pm and 1am. The administrator stated that R1 had fallen out of his wheelchair into a bush with a sprinkler outside, when it was approximately 40 degrees outside, without supervision.
The Administrator reported that on the date of the incident 2 of 3 staff scheduled to work arrived for their shift. All staff interviewed reported that R1 was not wearing a pendent, as they just moved in.
Of the staff interviewed, they stated that it is difficult to meet the needs of the residents.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae Boyles	TELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

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-20231211084559

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 GARDENS	FACILITY NUMBER: 045002775
	VISIT DATE: 01/29/2024

NARRATIVE

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Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099 D.

As a result of the resident sustaining an injury, an immediate civil penalty was assessed in the amount of $500.00 on 01/29/2024, on the attached LIC421IM.

Appeal rights were provided. An exit interview was conducted. A copy of the report was provided to the facility.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae Boyles	TELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20231211084559

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 GARDENS	FACILITY NUMBER: 045002775
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/29/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/02/2024 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs or the physical arrangements of the facility require such additional staff for the provision of adequate services. The requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee agrees to provide training for all direct care and administrative staff on the requirement to seek medical attention timely for residents. Licensee will schedule the training and provide CCL with the training content and signed staff attendance sheet as proof of correction.
	8 9 10 11 12 13 14	Based on observation, interviews and record review, the licensee did not provide adequate care and supervision by leaving a dementia resident unsupervised outside for an extended period of time which poses an immediate Health, Safety, Personal Rights risk to persons 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: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae Boyles	TELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC9099 (FAS) - (06/04)

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