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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002778
Report Date: 02/16/2022
Date Signed: 02/16/2022 01:52:35 PM


Document Has Been Signed on 02/16/2022 01:52 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 CAREFACILITY NUMBER:
045002778
ADMINISTRATOR:GUARINO, SAMANTHAFACILITY TYPE:
740
ADDRESS:2180 HUMBOLDT ROADTELEPHONE:
(530) 896-1990
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:16CENSUS: 7DATE:
02/16/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Eric PerryTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Jacob Williams conducted a case management visit to the facility on today's date for the purpose of delivering an Order To Individual of Immediate Exclusion from all facilities and the Order to Licensee/Facility of Immediate Exclusion From Facility. 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 respirator. Additionally, LPA was screened by staff upon entering the facility.

LPA met with current Executive Director, Eric Perry and explained the purpose of today's visit. Staff Pauline Willyard is excluded as a result related to this facility. LPA Williams handed the Order to Executive Director Facility of Immediate Exclusion From Facility letter to Eric Perry and explained that staff, Pauline Willyard is not allowed back at the facility.

A copy of this report was provided to Administrator.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob WilliamsTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2022
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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