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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002775
Report Date: 07/10/2024
Date Signed: 07/10/2024 01:25:25 PM


Document Has Been Signed on 07/10/2024 01:25 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 36DATE:
07/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator- Stacy Baxter TIME COMPLETED:
12:45 PM
NARRATIVE
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On July 10,2024, Licensing Program Analysts (LPAs),Jaynae Boyles and Farhaan Sarangi arrived unannounced at Roseleaf Gardens for the purpose of conducting a Case Management-Incident inspection.
During the Case Management-Incident inspection, LPA requested the following document(s):

-LIC 602
-Incident Report

During the Document Review of the LIC 602 (See Document review-LIC 602), the resident is unable to leave the facility unassisted. However, Resident R1 eloped from facility without staff knowledge on June 30, 2024. Current medical assessment dated for 4/5/23 for resident states resident is not able to leave facility unassisted.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Civil Penalties were assessed today for the amount of $250.00. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in additional civil penalties.


Exit interview was conducted with the Administrator and appeal rights were given to the Administrator.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024
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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Document Has Been Signed on 07/10/2024 01:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/10/2024
Section Cited
CCR
87411(a)

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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:
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Licensee/Administrator will submit a Plan of Correction on how future compliance will be met.
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Based on 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.
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Civil Penalties were assessed today for the amount of $250.00


Plan of Correction due on July 11, 2024.

Type B
07/10/2024
Section Cited
CCR87705(c)(5)

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Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
The requirement is not met as evidence by:
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The facility will develop and implement a strategy to track and monitor annual medical assessments for residents with Dementia, The Facility will inform the LPA of this process, and ensure that all annual medical assessments for residents for Dementia.
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Based on record review, the licensee did not provide provide an updated medical assessment for a dementia resident which poses a potential Health, Safety, Personal Rights risk to persons in care.
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Plans of Correction due by July 17, 2024
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: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024
LIC809 (FAS) - (06/04)
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