045002778-4-8-2022-25-AS-LMUZ-CDNQ2C-20220420114652

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045002778
Report Date: 04/08/2022
Date Signed: 04/08/2022 11:10:41 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/18/2021 and conducted by Evaluator Jaclyn Avila

COMPLAINT CONTROL NUMBER: 25-AS-20211118143230

FACILITY NAME:	ROSELEAF SENIOR CARE		FACILITY NUMBER:	045002778
ADMINISTRATOR:	TRISEL, DARREN		FACILITY TYPE:	740
ADDRESS:	2180 HUMBOLDT ROAD		TELEPHONE:	(530) 896-1990
CITY:	CHICO	STATE: CA	ZIP CODE:	95928
CAPACITY:	16	CENSUS: 6	DATE:	04/08/2022
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Samantha Guriano		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff do not assist residents with their incontinence needs

INVESTIGATION FINDINGS:

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On 04/08/2022 at 11:45 AM, Licensing Program Analyst (LPA) Jaclyn Avila arrived at the facility unannounced to conduct a complaint investigation. LPA met with Administrator Samantha Guarino and explained the purpose of the visit. Prior to initiating the complaint investigation 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; LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95

LPA explained the reason for the visit was to provide finding(s) for the above allegation(s). California Department of Social Service (CDSS) Community Care Licensing Division (CCLD) received a complaint alleging: Staff do not assist residents with their incontinence needs

Cont'd on 9099-C

Substantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

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 25-AS-20211118143230

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/08/2022

NARRATIVE

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This Department reviewed two resident files and found both residents were incontinent. During staff interviews, staff stated due to resident behaviors and lack of training with those behaviors, residents did not have their briefs changed. This department reviewed the “reported care report” and “Observations” which were authored by staff submitted to CCLD by the facility. This department observed that R1 last received incontinent care on 12/19/21 at 9:21 PM. On 12/20/21 at 05:18 AM, MT documents, “(R1) SLEPT MOST OF THE NIGHT I TRIED TO HELP R1 CHANGE BUT NO LUCK, AM SHIFT WILL BE INFORM AND WILL TRY.” The next entry is on 12/20/21 at 1203 PM which states, “Resident has refused care all day, but this writer did manage to change Resident's bedding. MT will try to later change Resident's brief.” The subsequent 3 entries are similar. Its not documented until 12/21/21 at 2:17 PM that R1 was changed, “Resident's bedding was fully changed and socks, pants and briefs as well.” However, on 12/21/21 at 11:33 PM its documented, “Resident had refused to allow PM shift staff to provide care despite being visibly saturated in urine. During shift change Med Tech was able to change resident and RA was able to provide bedding change during that time as well.”

On the Recorded Care Chart for R2 (Resident 2) observed on 12/21/21 at 11:04PM, incontinence care was completed. Incontinence care does not show completed again until 12/22/21 at 2:31 PM. The reasons listed by staff for not having completed incontinence care state, “Resident refused attempt to provide care, Resident refused becoming agitated and aggressive, etc..”

Roseleaf Senior Care is a facility that primarily accepts residents with diagnosis related to memory care. Interviews revealed NOC shift only has one caregiver who is med tech trained on at a time. AM Staff reported they would often come in and find R1 and R2 saturated in urine. Only administrative staff were able to provide ways that they can redirect to provide incontinence care. Care giving staff reported they are not trained in providing incontinence care to combative residents although Executive Director provided demonstrations with R1.

Substantiated Based on the departments observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. 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 Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20211118143230

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/08/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/09/2022 Section Cited CCR 87625(b)(3)	1 2 3 4 5 6 7	87625(b)(3) Managed Incontinence- In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry This requirement is not met as evidenced by: Based upon record review and interview	1 2 3 4 5 6 7	Licensee agrees to provide training on incontinence care and resident centered care. Licensee will provide training plans by 4/9/22
	8 9 10 11 12 13 14	the Licensee failed to ensure 2 of 2 residents were kept clean and dry. This poses a potential Health, Safety and/or Personal Rights risk to clients in care	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/18/2021 and conducted by Evaluator Jaclyn Avila

COMPLAINT CONTROL NUMBER: 25-AS-20211118143230

FACILITY NAME:	ROSELEAF SENIOR CARE		FACILITY NUMBER:	045002778
ADMINISTRATOR:	TRISEL, DARREN		FACILITY TYPE:	740
ADDRESS:	2180 HUMBOLDT ROAD		TELEPHONE:	(530) 896-1990
CITY:	CHICO	STATE: CA	ZIP CODE:	95928
CAPACITY:	16	CENSUS: 6	DATE:	04/08/2022
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Samantha Guriano		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Medication is left accessible to the residents in care
Facility has not provided residents with a call pendent

INVESTIGATION FINDINGS:

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On 04/08/2022 at 11:45 AM, Licensing Program Analyst (LPA) Jaclyn Avila arrived at the facility unannounced to conduct a complaint investigation. LPA met with Administrator Samantha Guarino and explained the purpose of the visit. Prior to initiating the complaint investigation 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; LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95
LPA explained the reason for the visit was to provide findings for the above allegation(s). California Department of Social Service (CDSS) Community Care Licensing Division (CCLD) received a complaint alleging: Medication is left accessible to the residents in care and Facility has not provided residents with a call pendent.

This department has conducted multiple site visits and has observed locked medications and call pendents.

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.

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 4