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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002775
Report Date: 01/27/2026
Date Signed: 01/29/2026 05:39:42 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
06/13/2025 and conducted by Evaluator Kayla Adkison
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250613155200
FACILITY NAME:ROSELEAF GARDENSFACILITY NUMBER:
045002775
ADMINISTRATOR:OWENS, JESSICAFACILITY TYPE:
740
ADDRESS:2770 SIERRA LADERATELEPHONE:
(530) 895-0800
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:56CENSUS: 25DATE:
01/27/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Bailey Malagon, AdministratorTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff did not seek medical attention in a timely manner.
Residents do not have access to personal hygiene items
INVESTIGATION FINDINGS:
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On January 27, 2026, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced for the purpose of delivering complaint findings. LPA was greeted by Administrator, Bailey Malagon, and explained the purpose of the visit. During the visit, there were 4 staff providing care and 25 residents.

During the course of the investigation, LPA reviewed pertinent documents, conducted interviews, and made observations of the facility.


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

DATE: 01/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026
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 5
Control Number 59-AS-20250613155200
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: 01/27/2026
NARRATIVE
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Allegation: Staff did not seek medical attention in a timely manner.

It was alleged that a resident had experienced two falls on the same day and staff members failed to seek medical attention for that individual. The complainant in this matter was unsure of the name of the resident, the number of the resident’s apartment at the facility, or the exact date of when the falls occurred. A physical description of the resident was provided; however, the resident was unable to be positively identified.

No staff interviewed were able to determine which resident this allegation may have been referring to.

Although the allegation may have happened, the preponderance of evidence has not been met, and the allegation is therefore UNSUBSTANTIATED.

Allegation: Residents do not have access to personal hygiene items

It was alleged that there was a significant shortage in personal hygiene items at the facility including, but not limited to, toothbrushes, lotion, hairbrushes , briefs, and personal wipes. During a facility inspection on June 18, 2025, LPA and Administrator conducted a tour of the facility. LPA observed a large closet full of excess wipes, briefs, and basic toiletries available for residents. Additionally, LPA observed residents’ personal toiletries that were kept in individual caddies for staff to use while assisting residents.

Six (6) of six (6) staff interviewed stated they have never observed any resident to go without briefs, wipes or basic toiletries. Staff stated that most resident's families provide any supplies they may need for the month and it is recorded on a log in the facility lobby. Any resident who's supplies were running low, staff notified the families. LPA observed a supply order list for the previous three months that contained toiletry items, multiple packages of briefs, anad multiple packages of wipes. LPA observed a "supply drop - off list" dated for the previous three months that had dozens of entries from family members dropping off supplies.

Although the allegation may have happened, the preponderance of evidence has not been met, and the allegation is therefore UNSUBSTANTIATED.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
06/13/2025 and conducted by Evaluator Kayla Adkison
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250613155200

FACILITY NAME:ROSELEAF GARDENSFACILITY NUMBER:
045002775
ADMINISTRATOR:OWENS, JESSICAFACILITY TYPE:
740
ADDRESS:2770 SIERRA LADERATELEPHONE:
(530) 895-0800
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:56CENSUS: DATE:
01/27/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Bailey Malagon, AdministratorTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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9
Facility not meeting incontinence needs of residents in care
INVESTIGATION FINDINGS:
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On January 27, 2026, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced for the purpose of delivering complaint findings. LPA was greeted by Administrator, Bailey Malagon, and explained the purpose of the visit. During the visit, there were XX staff providing care and XX residents.

During the course of the investigation, LPA reviewed pertinent documents, conducted interviews, and made observations of the facility.


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

DATE: 01/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 59-AS-20250613155200
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: 01/27/2026
NARRATIVE
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Allegation: Facility not meeting incontinence needs of residents in care

It was alleged that staff were not meeting the incontinence needs of residents in care by not supplying residents with depends/briefs when necessary and leaving residents in soiled briefs for an extended period. During the course of the investigation, LPA conducted several tours of the facility and observed a strong smell of urine in specific wings of the facility where it was known that resident's with incontinence issues were living. LPA attempted to interview residents who were on an incontinence plan, however, LPA was unsuccessful due to each resident’s dementia diagnosis.

On October 25, 2025 LPA was able to interview one (1) resident who indicated there have been several instances where they felt they were “forgotten” about by staff while residing at the facility. The resident indicated that the facility is regularly short staffed and there may have only been one (1) or two (2) staff members available to assist the entire facility. The resident admitted there had been times when they needed to use the restroom and were unable to get out of their bed on their own because staff never responded to their calls or assistance.

LPA interviewed several staff members during the course of the investigation. Four (4) of six (6) staff stated that they had observed residents being left in soiled briefs for an unknown extended period of time, particularly at shift changes. Staff stated that on more than one occasion, they would arrive for their shifts and find residents soaked through briefs, "chuck" pads, and down to their mattress while being asleep. Two (2) staff stated that it was facility policy to check residents hourly and it was unreasonable to believe that a resident could soak through their belongings that quickly, indicating staff were not properly meeting the incontinence needs of the residents.

Based on observations, interviews, and record review, 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 9099-D. Exit Interview conducted. A copy of this report and Appeal Rights were provided to Administrator, Bailey Malagon.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20250613155200
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: 01/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/06/2026
Section Cited
CCR
87625(b)(3)
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87625 Managed Incontinence (b) In addition to Section 87611... the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
This is evidenced by:
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Administrator agrees to fill out a LIC 9098 ensuring their understanding of the regulation. Administrator shall submit the form to LPA by end of busness on February 6, 2026.
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Based on observation, record review, and interviews, the licensee did not ensure that incontinence needs of residents were being met in that resdients were found soaked through their bedding at shift changes on more than one occasion and the facility has been observed to smell of urine which poses a potential health, safety, or personal rights risk to persons in care.
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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.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5