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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002778
Report Date: 11/22/2021
Date Signed: 11/22/2021 11:16:21 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:
(530) 896-1990
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:16CENSUS: DATE:
11/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Eric Perry - administratorTIME COMPLETED:
11:00 PM
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11/22/2021 11:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a case managment investigation. LPA met with administrator Eric Perry and explained the purpose of the visit. Prior to initiating the complaint investigation 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 administrator 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: N95 mask, gloves.

The reason for the visit is an incident report that was received on 11/09/2021, in which it was reported that a staff person had slapped and threatened a resident.

LPA requested copies of the following documents: Staff list with phone numbers, Resident's Physician's Report and admission agreement. More investigation and interviews are necessary.


No deficiencies were cited during today's visit. An exit interview was conducted, and a copy of the report was emailed to administrator Eric Perry.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5991
LICENSING EVALUATOR NAME: Rebecca KnightTELEPHONE: (530) 895-4356
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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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