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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002778
Report Date: 04/11/2023
Date Signed: 04/18/2023 07:06:24 AM


Document Has Been Signed on 04/18/2023 07:06 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833



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: DATE:
04/11/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Diania BinghamTIME COMPLETED:
12:30 PM
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On 04/11/23 Alycia Berryman, Regional Manager, Lauren Crocker, Licensing Program Manager, Donna Gurriere and Rebecca Knight, Licensing Program Analysts, Jaqueline Juarez, Audits Section Manager and Jessica Chen, Auditor held a non-compliance conference with Rajesh Rao, Sridhar Nagunuri, Sabi Bains, Ramaprasad Samudrala and Diania Bingham. The meeting was held via Teams.

The following information was discussed: On 07/11/22 a complaint was received and one of the allegations was that the facility was having financial issues. A request was made to the department’s audit unit to review all four facilities and their financial issues. A solvency audit was conducted during the months of July 2021 through August 2022. On 01/04/23 and 01/26/23, the audit unit reported the following:

Objective 1) To determine if the licensee has an adequate financial plan in compliance with CCR, Title 22, Section 87213 FINANCES, that assures sufficient resources to meet operating expenses for care and supervision of residents.
Finding 1) The licensee does not have an adequate financial plan to ensure residents’ care and supervision won’t be interrupted.
Finding 2): Inadequate Liability Insurance coverage.
Finding 3): Accountability of Licensee Governing Body Regulation – The late utility payments, insufficient funds & overdraft fees, inadequate general liability coverage noted indicates the licensee failed to exercise general supervision over the affairs of the licensed facilities.

Objective 2). To determine if the licensee is in good financial position and generates sufficient income to cover the operating expenses and meet short term obligations/liabilities
Finding 1): Overall, Roseleaf Oroville is not in a good financial standing due to negative incomes, falling behind on some large payments, and currently has negative equity.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023
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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: ROSELEAF SENIOR CARE
FACILITY NUMBER: 045002778
VISIT DATE: 04/11/2023
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1) The licensee will be cited for the following:
    a. CCR Title 22, Division 6, Section 87213 Finances;
    b. CCR Title 22, Division 6, Section 87205 Accountability; and
    c. Health and Safety Code, Section 1569.605 Liability Insurance.

2) Licensee shall be on financial monitoring for two (2) quarters or until it is evident a sound financial plan is in place and sustained
  1. Specifically, the licensee is to provide monthly utility bills and mortgage statements to the licensing agency to show the utility expenses are paid in-full by the noted due dates on the bills to avoid additional fees and disconnections of services;
  2. Licensee shall prepare and submit quarterly Profit and Loss Statement, with supporting documents;
    1. Specifically, revenue to be supported by the rent roll and bank statements showing funds have been deposited. Expenses to be supported by actual invoices and payments made;
  3. First quarter documents are to be submitted by the end of month following quarter end.

3) Licensee shall carry adequate general liability insurance required by law that each RCFE to be covered $1 million each occurrence and $3 million aggregate annually. A blanket coverage covering multiple facilities and businesses is not sufficient and not accepted.

Per today's meeting the requested documents shall be sent to Rebecca Knight, Licensing Program Analyst by 04/17/23. The requested audits documents shall be sent to the Audits Unit by 07/25/23.

Based on investigation 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), is 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 date; civil penalties may be assessed.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 04/18/2023 07:06 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833


FACILITY NAME: ROSELEAF SENIOR CARE
FACILITY NUMBER: 045002778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/17/2023
Section Cited

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Finances - The licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that assures sufficient resources to meet operating costs for care of residents; shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency…
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The licensee agrees to follow the recommendations that are indicated in the report.
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The licensee did not ensure that there were sufficient resources to meet operating costs for the care of residents.
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Type A
04/17/2023
Section Cited

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Accountability of Licensee Governing Body - The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves.
If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability.
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The licensee agrees to follow the recommendations that are indicated in the report.
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The licensees did not exercise general supervision over the affairs of their licensed facilities.
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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: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 04/18/2023 07:06 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833


FACILITY NAME: ROSELEAF SENIOR CARE
FACILITY NUMBER: 045002778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/17/2023
Section Cited

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Liability Insurance - On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.
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The licensee agrees to follow the recommendations that are indicated in the report.
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The licensee did not maintain liability insurance per the Health and Safety Code.
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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: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4