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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002775
Report Date: 08/06/2024
Date Signed: 08/06/2024 09:37:57 AM


Document Has Been Signed on 08/06/2024 09:37 AM - 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:BAXTER, STACYFACILITY TYPE:
740
ADDRESS:2770 SIERRA LADERATELEPHONE:
(530) 895-0800
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:56CENSUS: 38DATE:
08/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:MICHELLE LONGTIME COMPLETED:
10:00 AM
NARRATIVE
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On 08/06/24 Donna Gurriere, LPA is conducting a case management visit to follow up on a complaint investigation that was received on 05/03/24. Case Number: 59-AS-20240503152347. Met with Michelle Long, Administrative Assistant.

During the investigation of the complaint, it was determined that the facility staff were to record the date and time of each contact with the physician when giving a resident (Resident 1) her Pro Re Nata (PRN). In this case the staff were to contact the hospice nurse prior to giving the resident the PRN for Lorazepam and Phenobarbital, provide the date and time of each contact with the physician (hospice) and the physician’s (hospice) directions, were to be documented and maintained in the resident’s facility record. The staff did not document the contact with the physician (hospice) as required.

A separate citation will be given this date indicating that the staff did not document when the hospice nurse was contacted to provide the resident with the PRN.

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: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024
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 08/06/2024 09:37 AM - 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: 08/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/07/2024
Section Cited
CCR
87465(d)(1)(2)

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If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met: Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication. The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record.
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The administrator agrees to have a document in each resident’s file that indicates when the physician/hospice is called to give a PRN. This does not include the standard PRN letter related to over-the-counter meds.
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This requirement was not met as evidenced by: Based on interviews and records reviewed, the licensee did not ensure that a document indicating the date and time of each contact with the physician (hospice) and the physician’s (hospice) directions were documented and maintained in the resident’s file.
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 The administrator shall develop a document for each resident and shall submit a copy of what the document contains that the facility staff will use.
A skilled medical professional shall provide training to the staff in regards to the citation.

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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: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024
LIC809 (FAS) - (06/04)
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