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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002775
Report Date: 09/30/2025
Date Signed: 10/22/2025 04:47:22 PM

Unsubstantiated


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
04/10/2025 and conducted by Evaluator Kayla Adkison
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250410131635
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: 26DATE:
09/30/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Amanda Harb, Residential Care CoordinatorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
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3
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5
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7
8
9
Staff left residents in a soiled diaper for a long period of time.
INVESTIGATION FINDINGS:
1
2
3
4
5
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7
8
9
10
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12
13
On September 30, 2025, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility for the purpose of delivering complaint findings. LPA was greeted by Residental Care Coordinator, Amanda Harb, and explained the purpose of the visit. At the time of the visit, there were 26 residents in the facility and 3 staff providing care.


Continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
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 4
Control Number 59-AS-20250410131635
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: 09/30/2025
NARRATIVE
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Allegation: Staff left residents in a soiled diaper for a long period of time.

It was alleged that staff left a resident in soiled undergarments for an unknown, extended, period. LPA interviewed 4 staff members via telephone who all stated residents are changed as soon as possible. Staff reported there are several residents in the facility who are incontinent and require regular toileting care. Staff also reported there are a few residents who may become confused or combative when staff attempt to assist with toileting needs. Staff explained that because of this behavior, there are times when staff may need to allow a brief period when staff need to call for assistance or request a “change of face” for the resident by having a different staff member assist, however, no resident is left in soiled undergarments very long.

On April 18, 2025, LPA attempted to interview three residents at the facility but was unsuccessful.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to RCC, via email.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4
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
04/10/2025 and conducted by Evaluator Kayla Adkison
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250410131635

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: 26DATE:
09/30/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Amanda Harb, Residential Care CoordinatorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not seek medical attention in a timely manner.
Staff did not report an incident to licensing.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On September 30, 2025, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility for the purpose of delivering complaint findings. LPA was greeted by Residential Care Coordinator, Amanda Harb, and explained the purpose of the visit. At the time of the visit, there were 26 residents in the facility and 3 staff providing care.


Continued on LIC 9099-C
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 59-AS-20250410131635
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: 09/30/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
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32
Allegation: Staff did not seek medical attention in a timely manner.

It was alleged R1 sustained a fall, and the facility failed to seek medical attention for this resident in a timely matter.

On March 20, 2025, the department received an incident report documenting R1’s fall that occurred on March 19, 2025. The report further documented R1’s subsequent transport to the hospital for evaluation. Additionally, on March 28, 2025, the department received a separate incident report documenting another transport for R1 to the hospital for follow-up after R1’s bruising from the fall appeared to worsen.

Based on information above, it is concluded that the allegation is Unfounded. A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Allegation: Staff did not report an incident to licensing.

It was alleged that R1 had sustained a fall that the facility failed to report to licensing.

On March 20, 2025, an incident report was provided to Community Care Licensing via fax documenting a fall sustained by R1. Emergency Medical Services (EMS) was called and R1 was transported to the hospital for evaluation.

Based on information above, it is concluded that the allegation is Unfounded. A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted and a copy of this report was provided to Residential Care Coordinator, via email.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4