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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002778
Report Date: 06/08/2022
Date Signed: 06/08/2022 03:19:21 PM


Document Has Been Signed on 06/08/2022 03:19 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 SENIOR CAREFACILITY NUMBER:
045002778
ADMINISTRATOR:GUARINO, SAMANTHAFACILITY TYPE:
740
ADDRESS:2180 HUMBOLDT ROADTELEPHONE:
(530) 924-4804
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:16CENSUS: 6DATE:
06/08/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Golden Roseleaf Licensee and Peer Services LicenseeTIME COMPLETED:
11:35 AM
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An informal conference was conducted today via Microsoft Teams Platform. The purpose of this informal conference meeting is to discuss the inability to remain in substantial compliance with the regulations. Present in the meeting is Regional Manager Alycia Berryman, Licensing Program Manager Laura Munoz, Licensing Program Analyst Jaclyn Avila, Licensee Raj Rao, Chief of Operations Stephen Ratliff, Audre Smith, Dave Curtis interim CEO of Peer Services and Administrator Samantha Guarino. The informal conference process was explained during this meeting.

The facility has been cited 11 times in the last year. The facility was cited for the following issues: personal rights, staffing, incontinence care, activities, dementia care, etc. The facility was cited for 8 Type A citations, and 3 Type B citations. Three complaints were filed against the facility.


Issues discussed during the meeting were:
· Staffing issues and training
· Food Service
· Housekeeping
· Activities

Cont'd on LIC 809-C
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
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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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: 06/08/2022
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· Activities
· Medications
· Providing ADLs
· Licensee/Administrator accountability
· Transition as Peer Services separates as Licensee/Management
· Ensuring all staff regardless of position are fingerprint cleared and associated

The facility has stated they will do the following to achieve continued and substantial compliance:
· Increase the amount of training each staff receives
· Create policies and procedures to ensure staff are meeting needs of residents
· Maintain at least two direct care staff one of which is also a med tech
· Increase oversite of facility operations

The following Forms are due by June 10th, 2022 and are to be submitted to LPA
LIC 308

The following Forms are due by June 30th, 2022 and are to be submitted to LPA
Infection Control Plan

The following Forms are due by July 8th, 2022 and are to be submitted to LPA
LIC 500 Personnel report
Resident Roster LIC 9020
Activities Schedule
Medication Policy and Auditing System
LIC 309 and Organizational flow chart

Copy of this report will be e-mailed to the Licensee for Signature and a signed copy will be returned same day to LPA.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC809 (FAS) - (06/04)
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