045002778-12-30-2021-25-AS-JAVA-CA85AD-20211230184657

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 045002778
Report Date: 12/30/2021
Date Signed: 12/30/2021 06:49:44 PM

Document Has Been Signed on 12/30/2021 06:49 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 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: 11	DATE:	12/30/2021
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Executive Director Eric Perry		TIME COMPLETED:	07:15 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	On 12/30/21 at 10:30 AM, Licensing Program Analyst (LPA) Jaclyn Avila conducted an unannounced case management visit concerning two incident reports that were submitted to Community Care Licensing (CCL) on 12/16/2021. LPA met with Executive Director (ED) Eric Perry 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 Roseleaf Senior Care 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: PAPR. LPA completed the facility screening questionnaire. The first of two incident reports submitted on 12/16/2021 detailed that on 12/15/2021 near dinner time. S1 (staff 1) was witnessed entering R1’s (Resident 1) room with the intent to administer prescribed medication. S1 requested S2 grab resident’s legs. S1 was witnessed holding R1’s wrists against R1’s chest then placing the medication in R1’s mouth via syringe. S1 was then witnessed placing S1’s hands over R1’s mouth. Executive Director (ED) upon being notified of the incident notified R1’s responsible party, Ombudsman and Community Care licensing. Per the incident report medical treatment was not needed and S1 was suspended. The second incident report submitted to CCL on 12/16/2021 detailed that on 12/15/2021 at about 8 PM, S1 was witnessed entering R2’s room with the intent to “change” R2. S1 was allegedly witness holding R2 by the thumbs and hands even after it was suggested a different method be used. S1 was allegedly witnessed stating to R2, “that’s why you’re here, this is your prison sentence.” ED upon being notified of the incident reported to S2’s responsible party, ombudsman and CCL. Per the incident report medical treatment was not needed and S1 was suspended. cont'd on 812-C

SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Jaclyn Avila
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021

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 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: ROSELEAF SENIOR CARE	FACILITY NUMBER: 045002778
	VISIT DATE: 12/30/2021

NARRATIVE

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This department investigated the incident which consisted of document review and interviews which revealed that on 12/15/2021, S1 held R1 down by pinning both wrists against R1’s chest. S1 did this to administer crushed medication into R1’s mouth that R1 often refuses. S1 later restrained R2, who had documented behaviors, in order to change R2. The facility investigated the incident and spoke with S1 who admitted to knowing S1’s actions were wrong. Per the facilities investigation S1 admitted to holding R1 to get R1 to take medication and admitted to holding R2 to change him. ED reported to the responsible parties, ombudsman and CCL as required. ED however did not report incident to law enforcement within 24 hours as required. ED called in the reportable incidents to the Chico Police Department on 12/30/21 during the CCL site visit. ED terminated S1 on 12/27/21.

Both residents have memory care related conditions. The facility interviewed the residents shortly after the incident and neither resident could recall what occurred.

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. Report provided via e-mail.

SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Jaclyn Avila
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/30/2021 06:49 PM - It Cannot Be Edited

Created By: Jaclyn Avila On 12/30/2021 at 06:01 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: ROSELEAF SENIOR CARE	FACILITY NUMBER: 045002778
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/30/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/31/2021 Section Cited CCR 87468.2(a)(8)	1 2 3 4 5 6 7	87468.2(a)(8)-Personal Rights-To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.	1 2 3 4 5 6 7	Licensee agrees to assigned all staff Relias training on resident rights by COB on 12/31/21 and will have staff complete the training by 1/14/2022. Licensee agrees to conduct an inservice training on Title 22 related regulations . Licensee will provide the plan for the inservice training by COB on 12/31/21.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Interview and documentation. Licensee failed to protect 2 of 2 residents from physical abuse. This poses an immediate risk to residents 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:

Rayna L Bryson

LICENSING EVALUATOR NAME:

Jaclyn Avila

LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021

LIC809 (FAS) - (06/04)

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