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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002778
Report Date: 08/01/2021
Date Signed: 08/01/2021 11:30:33 AM

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:TRISEL, DARRENFACILITY TYPE:
740
ADDRESS:2180 HUMBOLDT ROADTELEPHONE:
(559) 970-1240
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:16CENSUS: 12DATE:
08/01/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Executive Director Eric PerryTIME COMPLETED:
12:00 PM
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On 8/1/21 at 10:00 AM, Licensing Program Analyst (LPA) Jaclyn Avila conducted an unannounced Case Management Health and Safety visit as directed by the department. LPA spoke with Executive Director Eric Perry by phone to announce the visit. LPA met with Eric and explained the reason for 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Additionally, LPA self screened and temperature checked at the faciilty.

LPA toured the facility inside and out including but not limited to facility dining areas, kitchen area and common areas. LPA observed that the facility was clean and free of any obstruction of pathways. LPA observed that the facility has all proper and required signs for COVID-19 prevention and safety protocol. LPA observed most sinks had hand washing signs posted. Hand washing areas are supplied with soap and paper towels. LPA observed all staff members wearing surgical masks. LPA observed hand sanitizers throughout the facility.

LPA discussed an off-site kitchen waiver with ED. ED expects he will have the facility staffed with a cook within a week. LPA will consult with LPM Rayna Bryson. ED expects the activities staff will return within the next two weeks. LPA granted an extension on the POC from the Administrator qualification citation issued on 7/31/21. The extension has been granted until 12PM on 8/2/21.

ED sent LPA the schedule for 8/1/21, LPA confirmed individuals scheduled were present at the facility. ED will send the schedule for the week by 6:30 AM on 8/2/21.

No citations issued.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2021
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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