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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002778
Report Date: 04/22/2022
Date Signed: 04/22/2022 02:00:15 PM


Document Has Been Signed on 04/22/2022 02:00 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:
04/22/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Administrator Samantha Guarino
Facility Designee Eric Perry		TIME COMPLETED:
02:15 PM
NARRATIVE
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On 4/22/2022 at about 11:15AM, Community Care Licensing (CCL) Licensing Program Analyst (LPA) Jaclyn Avila, Licensing Program Manager (LPM) Laura Munoz, and Regional Manager (RM) Alycia Berryman arrived at the facility unannounced to conduct a case management visit regarding facility compliance, CCL met with Administrator Samantha Guarino and Executive Director Eric Perry and explained the purpose of the visit. Prior to initiating the visit, CCL 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. CCL ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 and Surgical masks.

CCL met with Administrator Samantha Guarino in the facility's admin office. CCL interviewed the Administrator regarding staffing numbers, Administrator duties and resident needs. CCL toured the facility with facility designee Eric Perry. This facility currently has 6 resident's in care. 2 of 6 residents are receiving hospice care services. CCL staff observed 2 caregivers, 1 cook and the Administrator on duty during today's visit. In addition, CCL staff reviewed resident records while at the facility.

Based on interviews, observations and records review, the facility is currently understaffed to meet the needs of residents in care. It was learned that shifts run 12 hours and there is 1 staff working during the overnight shift. CCL observed 2 (R1 and R2) of 6 residents who are documented 2 person assists as well as 1 (R3) of 6 resident's who are documented as a fall risk. During interviews with staff, staff indicated they would not be able to independently assist R3 if R3 fell.

With the information above, the facility is being cited today per CCR, Title 2, Section 87411(a) as it has been identified that the facility will need additional staffing to meet the needs of the current residents in care.

Citations issued on the attached LIC809D. Exit interview and copy of report and appeal rights provided.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2022
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 04/22/2022 02:00 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: 04/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2022
Section Cited

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87411(a) Personnel Requirements. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
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This requirement has not been met as evidenced by: Based on documentation, interviews and observations, the facility has 3 of 6 people that require 2 person assist to meet care needs. The facility only staffs overnight shift with 1 staff which posses a potential health and safety risk to residents in care.
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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: 04/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2