<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002775
Report Date: 03/19/2024
Date Signed: 03/19/2024 11:32:36 AM

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
01/30/2024 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 59-AS-20240130112602
FACILITY NAME:ROSELEAF GARDENSFACILITY NUMBER:
045002775
ADMINISTRATOR:BINGHAM, DIANIAFACILITY TYPE:
740
ADDRESS:2770 SIERRA LADERATELEPHONE:
(530) 895-0800
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:56CENSUS: 35DATE:
03/19/2024
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:DON DANIELSTIME COMPLETED:
11:40 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide medication as prescribed.
Staff altered a resident's medication without consent.
Staff did not provide adequate supervision resulting in excessive falls.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 03/19/24 Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 01/30/24. LPA Gurriere met with Don Daniels and explained the purpose of the visit.

Staff did not provide medication as prescribed.
During the interview process, numerous documents were obtained. Documents included Physician’s Reports, Medication Administrative Records (MARs), Admission Agreements, Incident Reports, and prescription orders.

During the investigation, the administrator and several staff persons were interviewed. The residents were not interviewed due to their dementia status. A facility visit was conducted and the two residents (Resident 1 and Resident 2) in question had their medications reviewed by the LPA. Resident 1 had an order in place to allow for her medications to be crushed. During the time of the visit, Resident 2 did not have an order in place to alter the resident’s medications. Medication for Resident 2 was not given as prescribed.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
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-20240130112602
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: 03/19/2024
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
26
27
28
29
30
31
32
Staff altered resident medication without consent.
As stated in the aforementioned, Resident 1 and Resident 2 in question had their medications reviewed by the LPA. Resident 1 had an order in place to allow for her medications to be crushed. During the time of the visit, Resident 2 did not have an order in place to alter the resident’s medications. Medication for Resident 2 was altered without approval.

Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.

One citation is issued for both allegations, as the allegations overlap with one another.

Staff did not provide adequate supervision resulting in excessive falls.


During the interview process, documents were obtained. Documents included Incident Reports for the month of December 2023.

During the investigation, the administrator and several staff persons were interviewed. The residents were not interviewed due to their dementia status. The incident reports indicated that there were several falls by the residents. The administrator and several staff were asked if a process is in place when residents are at fall risk. It was reported that a procedure or a fall risk plan is not in place for individual residents. In addition, staff reported that they have not been trained on a specific “fall risk plan” for the individual residents that have ongoing falls.

Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.

Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 59-AS-20240130112602
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: 03/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/20/2024
Section Cited
CCR
87465(a)(6)
1
2
3
4
5
6
7
Incidental Medical - A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.
1
2
3
4
5
6
7
Administrator agrees to ensure that a physician’s order is in place to alter or crush a resident’s medication. The administrator will submit a copy of her understanding to the licensing agency
8
9
10
11
12
13
14
This requirement was not met as evidenced by interviews and documentation review. The licensee failed to ensure that a prescription order was in place to crush a resident’s medication. This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type A
03/20/2024
Section Cited
HSC
1569.269(a)(6)
1
2
3
4
5
6
7
Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
1
2
3
4
5
6
7
The administrator agrees to assess all residents that are a fall risk and prepare a plan. Training shall be provided to care providers regarding prevention practices of residents that are a fall risk. The administrator agrees to submit to the licensing agency the materials used to train the care providers and a sign in sheet of those that were trained.
8
9
10
11
12
13
14
This requirement was not met as evidenced by interviews and documentation review. The licensee failed to comply with the Health and Safety code cited above. A fall risk care plan was not in place. This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
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 CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3