045002775-4-25-2024-59-AS-LMUZ-D59PHQ-20240514112019

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045002775
Report Date: 04/25/2024
Date Signed: 04/25/2024 12:38:49 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
03/18/2024 and conducted by Evaluator Jaynae Boyles

COMPLAINT CONTROL NUMBER: 59-AS-20240318152248

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: 33	DATE:	04/25/2024
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Resident Care Corrdinator- Don Daniels		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff are not assisting to change resident's clothes regularly.

INVESTIGATION FINDINGS:

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04/25/2024 Licensing Program Analyst Jaynae Boyles made an unannounced visit to the facility and met with Resident care corrdinator. The purpose of this visit was to deliver the results of a complaint investigation.

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 LIC9099D. Appeal rights were provided. An exit interview was conducted. A copy of the report was provided to the facility.

Continued to 9099C

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: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240318152248

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: 04/25/2024

NARRATIVE

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LPA reviewed the following documents: Admissions agreement, preappraisal, care plan, medical assessment (602) and recorded care report for R1. The LPA interviewed R1.

LPA investigated the allegation, “Staff are not assisting to change resident's clothes regularly”. Documents reviewed indicated that R1 was assessed at the onset of placement for the need for assistance with dressing. R1’s medical assessment indicates that the resident needs assistance with dressing. R1’s care plan indicated that the facility would be providing the resident with assistance with daily dressing two times a day because the resident has use of only the left side due to a stroke.

Client interview revealed that the resident was not assisted in changing their clothing for four days, and this has occurred on more than one occasion. R1 could not remember the specific dates in which the previous incidents occurred. R1 indicated that when a specific staff is not present at work R1 is not assisted with changing their clothing.

LPA reviewed the residents Recorded Care report for the last two months at the facility. A review of this record indicates that this tool is not being utilized at the facility to document that the facility staff have completed the tasks with residents. The documentation within this document is inconsistent and sporadic with documentation of the completed tasks.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae Boyles	TELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20240318152248

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: 04/25/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/25/2024 Section Cited HSC 1569.2(c)	1 2 3 4 5 6 7	Care and supervision” means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care.	1 2 3 4 5 6 7	Facility agrees to create a plan to ensure that, residents are receiving the care outlined within their needs and services plan. Facility will ensure that staff are documenting the completion of the needs and services outlined in resident care plans. Facility will also conduct a training with staff regarding the importance of resident observation and documentation of ADLs and submit to LPA by the POC due date of 05/02/24.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: The resident was not assisted with dressing as an expressed need outlined in residents medical assessment, preapprasial and care plan from 3/11-3/15/2024, four days without assistance with dressing.	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: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC9099 (FAS) - (06/04)

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