045002778-1-28-2021-25-AS-JAVA-BXPNXR-20210128095134

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 045002778
Report Date: 01/27/2021
Date Signed: 01/28/2021 09:53:48 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926

FACILITY NAME:	ROSELEAF SENIOR CARE		FACILITY NUMBER:	045002778
ADMINISTRATOR:	TRISEL, DARREN		FACILITY TYPE:	740
ADDRESS:	2180 HUMBOLDT ROAD		TELEPHONE:	(559) 970-1240
CITY:	CHICO	STATE: CA	ZIP CODE:	95928
CAPACITY:	16	CENSUS: 13	DATE:	01/27/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	03:43 PM
MET WITH:	Eric Perry		TIME COMPLETED:	06:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Jaclyn Avila conducted a Pre-Licensing inspection of the facility via Facetime due to COVID 19 precautions. LPA Avila met with Administrator Eric Perry and Lead Med Tech Cindy Odor during the Tele-visit. The building consists of 1 kitchen, 13 resident bedrooms, 14 bathroom(s), 1 dining rooms, 2 living room, 1 laundry room. The facility has requested licensure for a capacity of 16 residents (16 non-ambulatory, 4 bedridden, 4 hospice). Currently there are 13 residents in the facility. LPA Avila toured the facility with the administrator and med tech. The physical plant is consistent with the submitted facility sketch/floor plan. The facility is clean and in good repair. The facility temperature is between 72 degrees and 75 degrees. All window screens are clean and in good repair. There is appropriate lighting in the facility and in each room. There is a locked centralized storage area for resident medications. Protective devices are in use such as non-slip material on rugs. Indoor and outdoor passageways and stairways are free of obstruction. Stairways, inclines, ramps, open porches, and areas of potential hazard accessible to residents are well-lit and equipped with sturdy hand railings. Disinfectants, cleaning solutions, poisons, and other items which could pose a danger are inaccessible. Fire alarms and smoke alarms operate properly. Carbon monoxide detectors operate properly. Resident bedrooms are large enough to allow for easy passage between and comfortable usage of beds and other required items of furniture, and any resident assistant devices such as wheelchairs or walkers. There is a bed for each resident equipped with good springs, clean and comfortable mattress, pillow(s), and bedding. There is a chair, night stand, chest of drawers, and lamp or sufficient lighting for each resident. Bathroom floors are clean, sanitary, and odorless. The hot water temperature is between 105-120 degrees Fahrenheit. All bathtubs, showers, and toilets have grab bars. All bathtubs and showers have non-skid mats or strips. All bathtubs, showers, toilets, and sinks operate properly. There is at least one (1) toilet and sink for each six (6) persons, which includes residents, family and personnel.

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2021

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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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 COHASETT RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ROSELEAF SENIOR CARE	FACILITY NUMBER: 045002778
	VISIT DATE: 01/27/2021

NARRATIVE

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Night-lights are present in hallways outside non-private bathrooms. There is a sufficient supply of hygiene items such as soap and toilet paper. There is a sufficient supply of clean linen, including blankets, bedspreads, top sheets, bottom sheets, pillowcases, mattress pads, bath towels, hand towels, and wash cloths.

Kitchen and dining room floors are clean. There are no pesticides, poisons, or other toxic substances stored in any food storage or preparation area or with utensils. Cleaning supplies are kept in areas separate from food supplies. Freezer is -4 degrees Fahrenheit. The refrigerator is 38 degrees Fahrenheit. A seven (7) day supply of non-perishable food is present. There are sufficient amounts of equipment for the storage, preparation, and service of food.

There is confidential storage of personnel records at the facility. There is confidential storage of resident records at the facility.

Emergency exiting plans and telephone numbers are posted. Facility Theft and Loss Program is posted. The Licensing Complaint Poster is posted. Resident Personal Rights are posted. Posting Title 22, Section 87468 and Health and Safety Code, Section 1569.269 meets this requirement. Resident Council Rights are posted. Posting a copy of the Rights of Resident Councils PUB 747 meets this requirement.

There is a first aid kit, including sterile dressings, bandages, thermometer, scissors, tweezers, and a current first aid manual. There are laundry supplies and equipment, including at least one machine in good repair.

There is an operating telephone available to residents. Emergency lighting supplies e.g., flashlights, batteries are present. Vehicles used to transport residents are in safe operating condition.

Cont'd on LIC 809-C

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2021

LIC809 (FAS) - (06/04)

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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 COHASETT RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ROSELEAF SENIOR CARE	FACILITY NUMBER: 045002778
	VISIT DATE: 01/27/2021

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DEMENTIA CARE
Knives, matches, tools and other items that could constitute a danger are inaccessible. Over the counter medications, nutritional supplements or vitamins, alcohol, and cigarettes are inaccessible. Toxic substances such as certain plants, gardening supplies, cleaning supplies, and disinfectants are inaccessible. Outdoor activity space is completely enclosed by a fence with self-closing latches and gates, or walls. Auditory devices are in place to monitor exits, if exiting presents a hazard to any resident.

LPA observed an empty water display at the center of the facility's back courtyard. The display consisted of various sized rocks/boulders that are piled is the shape of a waterfall. The tallest point being approximately 2.5 feet. At the bottom of this display is an area deep enough that water is pooling. The population that the facility serves are those who require memory care to include persons with the diagnosis of dementia. This area of concern is in violation of 87307 Personal Accommodations and Services (d)(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well lighted.

Comp III reviewed with Administrator.

No citations issues during today’s tele-visit. Pre-Licensing is incomplete with deficiencies to be resolved by 2/5/2021.

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2021

LIC809 (FAS) - (06/04)

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