045002778-11-9-2022-25-AS-TORZ-CM33HF-20221212171550

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045002778
Report Date: 11/09/2022
Date Signed: 11/09/2022 12:03:13 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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
11/07/2022 and conducted by Evaluator Kerry Hiratsuka

COMPLAINT CONTROL NUMBER: 25-AS-20221107093224

FACILITY NAME:	ROSELEAF SENIOR CARE		FACILITY NUMBER:	045002778
ADMINISTRATOR:	GUARINO, SAMANTHA		FACILITY TYPE:	740
ADDRESS:	2180 HUMBOLDT ROAD		TELEPHONE:	(530) 924-4804
CITY:	CHICO	STATE: CA	ZIP CODE:	95928
CAPACITY:	16	CENSUS: 8	DATE:	11/09/2022
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Audre Smith and Kelly White		TIME COMPLETED:	12:12 PM

ALLEGATION(S):

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Facility did not have the food supply required by the regulations
Facility staff are not able to serve residents food listed on the menu

INVESTIGATION FINDINGS:

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LPA Hiratsuka, conducted this unannounced complaint visit. LPA wore a surgical mask during visit and observed all staff wearing surgical masks.

LPA inspected the food supply. Title 22 Regulations 87555(b)(26) General Food Service Requirements: Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. LPA observed one half loaf of bread, 4 2lb cans of fruit, 6 15.3 oz cans of corn, one package of hamburger buns, cereal, some snack foods, and the rest was dry ingredients that could not be used by themselves as food. There was about 15 small sweet potatoes and about 14 oranges and eight bananas. This does not meet the requirements. There is not enough nonperishable food for three meals a day for seven days for eight residents. LPA was informed during this visit there are residents moving out today. LPA was informed prior to this visit the licensee gave 60 day notice of closure and residents are moving out because of that.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20221107093224

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ROSELEAF SENIOR CARE	FACILITY NUMBER: 045002778
	VISIT DATE: 11/09/2022

NARRATIVE

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Title 22 Regulations 87555(b)(6) General Food Service Requirements: In facilities for sixteen (16) persons or more, menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days. Facilities licensed for less than sixteen (16) residents shall maintain a sample menu in their file. Menus shall be made available for review by the residents or their designated representatives and the licensing agency upon request. LPA requested a copy of the menu and was told one is not available. The cook makes meals based on the available ingredients. Because there is no menu the facility does not have proof there is enough ingredients to make meals for the residents and meet any diets prescribed by doctor.

Based on all the above, the allegations are substantiated.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code. Failure to correct shall result in civil penalties.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 25-AS-20221107093224

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ROSELEAF SENIOR CARE	FACILITY NUMBER: 045002778
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/09/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/10/2022 Section Cited CCR 87555(b)(26)	1 2 3 4 5 6 7	General Food Service Requirements. The following food service requirements shall apply: Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. Based on observation Licensee failed this by:	1 2 3 4 5 6 7	By 11/10/2022, the facility shall have a seven day nonperishable food supply and shall maintain it based on the number of residents until the facility closes.
	8 9 10 11 12 13 14	LPA observed 4 2lb cans of fruit, cereal, one package of hamburger buns, a partial loaf of bread, some fruits and vegetables, and snack food. This does not mee the nonperishable food supply requirement. This is an immediate health and safety risk to residents.	8 9 10 11 12 13 14
Type A 11/18/2022 Section Cited CCR 87555(b)(6)	1 2 3 4 5 6 7	General Food Service Requirements. In facilities for sixteen (16) persons or more, menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days. Licensee failed this based on observation.	1 2 3 4 5 6 7	By 11/10/2022, the licensee shall come up with a set menu and the food supply shall meet the menu.
	8 9 10 11 12 13 14	The facility does not have a menu for LPA to review and therefore does not have proof they have enough ingredients for the meals that are prepared. This is an immediate health and safety risk to residents.	8 9 10 11 12 13 14

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: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022

LIC9099 (FAS) - (06/04)

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