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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002778
Report Date: 04/13/2022
Date Signed: 04/13/2022 04:30:31 PM


Document Has Been Signed on 04/13/2022 04:30 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) 924-4804
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:16CENSUS: 6DATE:
04/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Staff Anna McFarland and ED Eric PerryTIME COMPLETED:
04:45 PM
NARRATIVE
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On 4/13/2022 at about 2:00 PM Licensing Program Analysts (LPA) Jaclyn Avila and David Loperena arrived at the facility unannounced to conduct a required - 1 - year annual regarding infection control, LPAs met with Staff Anna McFarland and Executive Director Eric Perry and explained the purpose of the visit. Prior to initiating the visit, LPAs 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: N95.

LPAs toured the facility with med tech Anna McFarland to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident rooms, common bathrooms, dining room, visiting area and storage areas.

At approximately 2:15 PM, LPAs and MT McFarland observed room #180. LPA observed the carpet to be soiled and stained. LPA observed food crumbs and a breakfast sausage link underneath the residents bed along with other unidentifiable debris. In the attached bathroom, personal hygiene items were located and accessible on the bathroom sink. LPA reviewed the Residents Physicians report and found the doctor determined the personal hygiene items pose a risk to resident if not supervised. Resident was alone at time of inspection.

At approximately 2:26 PM, the kitchen was toured and containers with food were observed to not be labeled or opened and packaged. ED agreed to have the food audited today and kitchen disinfected today.

The following deficiencies were cited per Title 22 of the California Code of Regulation see LIC 809D. 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 dates; civil penalties may be assessed.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022
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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Document Has Been Signed on 04/13/2022 04:30 PM - 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: ROSELEAF SENIOR CARE
FACILITY NUMBER: 045002778

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
87303(a)-Maintenance and Operation- The facility shall be clean, safe, sanitary and in good repair at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 resident rooms which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/14/2022
Plan of Correction
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Licensee agrees to create a check list of daily duties for house keeping. Licensee agrees to submit the check list sheet of daily duties and policy by COB on 4/14/2022 to CCLD
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2022
LIC809 (FAS) - (06/04)
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