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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002778
Report Date: 07/31/2021
Date Signed: 07/31/2021 05:27:06 PM

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 SENIOR CAREFACILITY NUMBER:
045002778
ADMINISTRATOR:TRISEL, DARRENFACILITY TYPE:
740
ADDRESS:2180 HUMBOLDT ROADTELEPHONE:
(559) 970-1240
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:16CENSUS: 12DATE:
07/31/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Executive Director Eric Perry
Administrator Darren Trisel		TIME COMPLETED:
06:00 PM
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7/31/21 at 11:00 AM Licensing Program Analyst (LPA) Jaclyn Avila arrived at the facility unannounced to conduct a case management regarding staffing. LPA met with Executive Director Eric Perry, Administrator Darren Trisal 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 related symptoms; contacted administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. LPA completed facility screening

Currently, there are 2 staff scheduled for day shift, 2 scheduled for PM shift and 1 scheduled for night shift. Per ED, this is normal staffing, the difference is that he is filling shifts and there is no cook. Food is being transported from Roseleaf Gardens to Roseleaf Senior Care. Currently there is not a designated activities person and scheduled activities are taking place twice a week. Activities are not posted. ED has reached out to local registries to assist with staffing to no unveil. LPA confirmed ADLS of residents are being met.

At 1:07 PM, LPA walked into the common area of the facility where residents were sitting after their lunch. LPA noted that the kitchen door was left open and did not observe staff in the kitchen or in the common area with 8 residents. Accessible to residents in care were 7 knives. 1 knife was left on the counter top just to the left as you enter into the kitchen. The remainder of the knives were on a magnetic board above the gas stove. At 1:27 PM, LPA observed that staff had not returned to the area and the knives were still accessible. LPA knocked on the administrator's office door which was closed and retrieved Administrator Darren Trisel to advise him. Darren immediately locked up the kitchen making the knives inaccessible.

The facility will provide the LIC 500 (personnel roster) to Community Care Licensing (CCL) by 6:30 PM today (7/31/21). The facility will immediately e-mail CCL with any changes to the staff schedule. If there is a call out, the facility will e-mail CCL and notify CCL as to what their plan is to fill the shift. These updates will take place until further notice.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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 SENIOR CARE
FACILITY NUMBER: 045002778
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/31/2021
Section Cited

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87705(f)(1)-Care of Residents with Dementia-The following shall be stored inaccessible to residents with dementia:(1) Knives, matches, ...and other items that could constitute a danger to the resident(s).

This requirement was not met as evidenced by:
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Interview and observation. Administrator and facility staff failed keep knives inaccessible to 8 of 8 residents in care. This poses an immediate risk to residents in care
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Type A
08/01/2021
Section Cited

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87405(a)-Adminsitrator Qualifications-All facilities shall have a qualified and currently certified administrator. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility.
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This requirement was not met as evidenced by:
Interview and observation: Administrator has failed to be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility. This poses an immediate 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: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2021
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 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: ROSELEAF SENIOR CARE
FACILITY NUMBER: 045002778
VISIT DATE: 07/31/2021
NARRATIVE
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On 7/30/21, CCL held a meeting with Peer Services INC regarding staffing. CCL cannot grant a waiver or exception to the following regulation:

87224 Eviction Procedures-
(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5)Change of use of the facility. (A) The licensee may, upon no less than sixty (60) days written notice, evict a resident due to change of use of the facility. 1. In addition to written notice to quit requirements specified in Section 87224(d), written notice to evict due to change of use of the facility shall be made to the resident or the resident’s responsible person and shall include all requirements specified in Section 1569.682(a)(2)(A) through (F) of the Health and Safety Code.

Administrator Darren Trisal is requesting it be documented that he will be appealing administrator qualifications.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights provided.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2021
LIC809 (FAS) - (06/04)
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