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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 11:00:09 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
11/02/2021 and conducted by Evaluator Jaclyn Avila
COMPLAINT CONTROL NUMBER: 25-AS-20211102083921
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:
05:20 PM
ALLEGATION(S):
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Residents are not getting needs met due to understaffing.
The administrator is not often present at the facility.
Activities are not provided.
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: Residents are not getting needs met due to understaffing. The administrator is not often present at the facility. Activities are not provided. This complaint has been investigated and following are the findings:

Cont'd on 9099C
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 6
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
11/02/2021 and conducted by Evaluator Jaclyn Avila
COMPLAINT CONTROL NUMBER: 25-AS-20211102083921

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:
05:20 PM
ALLEGATION(S):
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2
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8
9
There is no activity director.
Facility is not kept clean.
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: There is no activity director and Facility is not kept clean. This department conducted interviews and conducted multiple site visits. A minority of individuals interviewed stated they felt the facility was unkept and had insects. This was not observed by the department or the majority of those interveiwed. Facility has an activities director however this staff person primarly works out of sister facility Roseleaf Gardens.

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: 2 of 6
Control Number 25-AS-20211102083921
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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Roseleaf Senior Care is a facility that primarily accepts residents with diagnosis related to memory care. Interviews revealed NOC shift only has one caregiver who is med tech trained on at a time. AM Staff reported they would often come in and find R1 and R2 saturated in urine. Review of records indicated NOC was not providing incontinence care to all residence during an 8-hour shift. Staff reported there were 2-3 residents who required a 2 person assist and had a Hoyer lift. Staff said the policy for the Hoyer lift is that 2 people are required to operate it. Although the Licensee retained residents who requires 2 staff to assist, the facility only scheduled 1 person during NOC shift.

Interviews and review of documents revealed on 12/2/2021, a med tech was transferring a hospice resident (R1) from R1’s bed to wheelchair. R1 was a two person transfer however R1 transferred resident without the assistance of another staff member. This resulted in R1 falling sustaining a bloody nose, a skin tear to R1’s neck, and wrist. Due to R1 being on hospice, R1 was not transferred out and treated by Hospice staff at the facility.

The facility has experienced two COVID outbreaks, the first being with staff in August 2021 and the 2nd being in January and February of 2022. The 2nd outbreak consisted of multiple residents. Instead of isolating residents in their rooms, the facility due to lack of staffing, sent residents out to Colusa Medical Center for their isolation period regardless of being asymptomatic or having mild symptoms.

Interviews and LPA observation revealed activities were not being provided from August until November 2021 due to lack of staffing. Interviews revealed the facility maintained 1 med tech and 1 caregiver during AM and PM shifts however there was not consistently a cook at the facility or activities being done. On 7/31/21 and 8/1/21, this department conducted a health and safety check due to the facility self-reporting a staffing shortage. During these visits, this department observed residents sitting in silence, in a circle facing each other for hours. The facility said they were utilizing activities staff for care giving.

Cont'd 9099-C

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: 3 of 6
Control Number 25-AS-20211102083921
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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Interviews conducted revealed staff did not know who the listed administrator was to include what Darrin Tristal’s role was at the facility. Most staff had not met him. At the time of this complaint Licensee Peer Services had Darrin Tristal listed as administrator. The Chico Regional Office, who provides oversight to Roseleaf Senior Care, requested copies of documents to list Executive Director Eric Perry as administrator however Darrin refused due to providing requested documents during the application process with the Centralized Application Unit. In January 2022, Peer Services requested to list Samantha Guriano as the Administrator.

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: 4 of 6
Control Number 25-AS-20211102083921
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
87219(a)
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87219(a)-Planned Activities-Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities.

This requirement is not met as evidenced by:
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Licensee agrees to provide 32 hours of activities to residents in care weekly. Licensee will provide a schedule to CCL outlining the activities and staff dedicated to conduct the activities by 4/9/22.
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Based upon observation and interview the Licensee failed to provide all residents in care with the opportunity to participate in planned activities.

This poses an immediate Health, Safety and/or Personal Rights risk to residents in care.
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Type A
04/09/2022
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements – General-Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This requirement is not met as evidenced by:
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Licensee agrees to provide CCL with a plan by 4/9/2022 to ensure personnel will be sufficient in numbers and competent.
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Based upon observation and interview the Licensee failed to ensure staff are sufficient in numbers and competent to provide services necessary to meet resident needs.

This poses an immediate Health, Safety and/or Personal Rights 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: 04/08/2022
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 6
Control Number 25-AS-20211102083921
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
04/22/2022
Section Cited
CCR
87405(h)(8)
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87405(h)(8) Administrator - Qualifications and Duties-The administrator shall have the responsibility to: Have the personal characteristics, physical energy and competence to provide care and supervision and, where applicable, to work effectively with social agencies.
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Licensee cleared POC prior to today's visit. Licensee has hired a new administrator.
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This requirement is not met as evidenced by: Based upon observation and interview the Licensee failed to have an administrator with the personal characteristics, competence and ability to work effectively with social agencies.

This poses a potential Health, Safety and/or Personal Rights 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: 04/08/2022
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: 6 of 6