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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002775
Report Date: 03/09/2022
Date Signed: 03/09/2022 03:32:28 PM


Document Has Been Signed on 03/09/2022 03:32 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:ROSELEAF GARDENSFACILITY NUMBER:
045002775
ADMINISTRATOR:PERRY, ERICFACILITY TYPE:
740
ADDRESS:2770 SIERRA LADERATELEPHONE:
(530) 895-0800
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:56CENSUS: 24DATE:
03/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:02 PM
MET WITH:Administrator Eric PerryTIME COMPLETED:
03:15 PM
NARRATIVE
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On 03/09/2022 at 12:00 PM, Licensing Program Analyst (LPA) Jaclyn Avila and Licensing Program Manager (LPM) Laura Munoz arrived at the facility unannounced to conduct a case manager related to a self reported incident. LPA and LPM met with Executive Director Eric Perry and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. Additionally, LPA Avila and LPM Munoz were screened by care staff upon entrance to the facility.

On 2/24/2022, LPA Avila received a call from Administrator Eric Perry, notifying Community Care Licensing (CCL). Eric self reported an incident that occurred on 2/20/2022. Eric said a resident ate a "Mop Pod." Eric said a newly hired staff was cleaning and left his cart unattended while cleaning. Staff realized a resident was chewing on something and went to the Med Tech. The Med Tech called EMS who responded. Eric said he has already ordered new carts with a locking mechanism to prevent this incident from happening again. Eric later submitted the LIC 624 ( unusual incident report), LIC 602 (Physicians report), and hospital discharge paperwork.

At time of visit, LPA reviewed the discharge paperwork from the hospital which stated ingestion of foreign substance.

LPA requested to see the "Mop Pod." The cleaner is from Sysco called Reliance Floor Cleaner. The warning on the container under Warning states "dangerous gases (chlorine)." The pods are pink in color and approximately 1 by 1 inch.

The following deficiencies were cited per Title 22 of the California Code of Regulation (See LIC 9099D or 809D). 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 dates; civil penalties may be assessed.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022
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 03/09/2022 03:32 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: ROSELEAF GARDENS
FACILITY NUMBER: 045002775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2022
Section Cited

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87705(f)(2)-Care of Persons with Dementia-The following shall be stored inaccessible to residents with dementia:cleaning supplies and disinfectants.

This requirement is not met as evidenced by: Based upon interview and review of documents the Licensee failed to-
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Keep cleaning supplies from 1 of 1 residents in care.

This poses an immediate Health, Safety and/or Personal Rights risk to residents 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.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022
LIC809 (FAS) - (06/04)
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