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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002778
Report Date: 04/08/2022
Date Signed: 04/08/2022 10:47:03 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/21/2021 and conducted by Evaluator Jaclyn Avila
COMPLAINT CONTROL NUMBER: 25-AS-20211021082114
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: 6DATE:
04/08/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Samantha GuarinoTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility is not reporting incidents to Community Care Licensing.
Residents are not receiving medical care timely.
Resident received an injury while in care.
INVESTIGATION FINDINGS:
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On 04/08/2022 at 11:45 AM, Licensing Program Analyst (LPA) Jaclyn Avila arrived at the facility unannounced to conduct a complaint investigation. LPA met with Administrator Samantha Guarino 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; LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95

LPA explained the reason for the visit was to provide finding(s) for the above allegation(s). California Department of Social Service (CDSS) Community Care Licensing Division (CCLD) received a complaint alleging: Facility is not reporting incidents to Community Care Licensing, Residents are not receiving medical care timely and resident received an injury while in care. This department has investigated the allegations and the following are the findings:

Cont'd on 9099-C
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/21/2021 and conducted by Evaluator Jaclyn Avila
COMPLAINT CONTROL NUMBER: 25-AS-20211021082114

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:
04/08/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Samantha GuarinoTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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9
Staff did not perform first aid for resident.
INVESTIGATION FINDINGS:
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On 04/08/2022 at 11:45 AM, Licensing Program Analyst (LPA) Jaclyn Avila arrived at the facility unannounced to conduct a complaint investigation. LPA met with Administrator Samantha Guarino 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; LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95

LPA explained the reason for the visit was to provide findings for the above allegation(s). California Department of Social Service (CDSS) Community Care Licensing Division (CCLD) received a complaint alleging: Staff did not perform first aid for resident. This department conducted interviews and reviewed observation records and did not observe an incident where it was appropriate for staff to provide first aid. All staff interviewed confirmed this.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 25-AS-20211021082114
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 04/08/2022
NARRATIVE
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The complainant did not provide a specific incident nor a specific resident. This department pulled a sample of residents based on interviews with staff, to review.

During staff interviews, this department found staff are not ensuring residents are receiving medical care timely, this was confirmed by record review. Staff provided a name of resident (R1) who they observed had a change in condition. Staff stated the resident started throwing up and was not at resident’s baseline. Staff admitted to not summoning EMS at time of observation which was documented on 12/17/2021 at 3:02PM.

Upon further review of staff observations, provided to the department by Roseleaf Executive Director, in excel sheet format, this department noted that staff believed R1 had a UTI (urinary track infection) on 12/10/2021 at 8:14 PM. The next entry is listed as a “critical” observation on 12/11/21 at 7:30 PM stating R1 was in bed all day and refused all meals. On 12/11/21 at 10:28PM, staff notes R1 had no urine output. There are no observation notes until 12/12/21 at 8:57 PM which is listed as critical stating, R1 has large skin discoloration on the right side of R1’s head and R1 has no recollection of what happened. On 12/13/21 at 2:02 PM, Staff note R1 woke up at 8AM and had stayed in bed at an awkward angel since awakening. Staff attempted several times throughout breakfast to get R1 to join the others at breakfast but R1 declined. On 12/13/21/ at 10:25 PM, staff noted resident has a red and purple skin discoloration on her left knee. Its not documented until 12/18/21, R1 had been to the emergency room under staff observations. From 12/10/2021-12/18/2021, although staff notated “critical” observations to include change in condition and injuries to R1’s head and knee, R1 did not receive medical care. This department confirmed R1 was sent out on 12/17/2021 at the request of the responsible party after being contacted by the facility's med tech as directed by Executive Director Eric Perry, at which time R1 was hospitalized however this was not reported to CCLD. Staff interviews confirmed these observations and staff who observed changes in condition and bruising did not summon medical.

Substantiated Based on the departments observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. 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: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 25-AS-20211021082114
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/09/2022
Section Cited
CCR
87466
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87466 Observation of the Resident- The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.
This requirement was not met as
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Licensee agrees to review observation logs daily and will provide training to staff regarding observations and informing administrative staff of changes in condition. Licensee agrees to provide CCL with a written plan on 4/9/22
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evidenced by: Based on record review and interviews, Licensee did not observe for changes and provide appropriate assistance to those changes for 1 of 1 resident which poses an immediate health and safety risk for resident in care.
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Type A
04/11/2022
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4)-Additional Personal Rights of Residents in Privately Operated Facilities-residents...shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs
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Licensee agrees to contact the ombudsmen and have an in-service training on personal rights of residents. Licensee agrees to submit a date and time of training by COB on 4/11/22 to CCL and will submit a roster of those in attendance at time of training.
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This requirement was not met as evidenced by: Based on record review and interviews, Licensee did not provide resident's right to care, supervision and services for 1 of 1 residents in care. This poses an immediate health and safety risk for resident 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: 04/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 25-AS-20211021082114
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/15/2022
Section Cited
CCR
87211(a)(1)(D)
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87211(a)(1)(D)-Reporting requirements- A written report shall be submitted to the licensing … within 7 days of the occurrence …Report shall include resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Any incident which threatens the
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Licensee agrees to conduct an in-service of regulation 87211 CCR with staff by 4/15/22. Licensee agrees to provide CCL with a roster of staff in attendance at time of training.
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welfare, safety or health of any resident.This requirement was not met as evidenced by interview and record review: Licensee failed to report injuries and hospitalization of 1 of 1 residents in care. This poses a potential risk to the health and safety of 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: 04/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5