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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002773
Report Date: 08/27/2026
Date Signed: 08/27/2026 12:02:09 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/13/2026 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 59-AS-20260713084241
FACILITY NAME:ROSELEAF OROVILLEFACILITY NUMBER:
045002773
ADMINISTRATOR:HAWKINS, GRACEFACILITY TYPE:
740
ADDRESS:1900 20TH STTELEPHONE:
(530) 538-8200
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY:60CENSUS: 26DATE:
08/27/2026
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Grace Hawkins - executive directorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Inadequate staffing over July Fourth holiday weekend.- SUBSTANTIATED
Facility does not have an activities director. - SUBSTANTIATED
Facility is malodorous. – SUBSTANTIATED
Housekeeping services are inadequate. - SUBSTANTIATED
INVESTIGATION FINDINGS:
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08/27/2026 10:30 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to deliver the results of a complaint investigation. LPA met with administrator Grace Hawkins and explained the purpose of the visit.

During the course of the investigation LPA toured the facility, conducted interviews and reviewed documents.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2026
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 7
Control Number 59-AS-20260713084241
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ROSELEAF OROVILLE
FACILITY NUMBER: 045002773
VISIT DATE: 08/27/2026
NARRATIVE
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Inadequate staffing over July Fourth holiday weekend. - SUBSTANTIATED

It was reported that on the weekend of July 4th the facility was down to 1 care giver and 1 med tech for the whole facility.

LPA reviewed staffing schedule for the weekend of July 3 - 5 2026. The facility used Clipboard registry to fill in staffing gaps that weekend with the exception of July 5 when the registry did not provide any staffing to the facility. July 3 and July 4 show 1 med tech and 2 care staff for the AM and PM shifts, NOC shift had 1 med tech and 1 care staff both days. July 5 shows 1 med tech and no care staff for the AM shift, PM shift shows 1 med tech and 1 care staff, NOC shift had 1 med tech only on shift.

It was determined that the facility did not have enough staffing on July 5, 2026 in particular. This allegation is substantiated.

Facility does not have an activities director.- SUBSTANITATED

It was reported that the facility does not have an activities director.

During staff interviews it was learned that staff provided activities for the residents while the facility did not have an activities director.

ED stated the last activities director left employment the first week of June. The facility had recently hired a new activities director and they were scheduled to start that week.

It was determined that the facility had been without an activities director for approx. 6 weeks. This allegation is substantiated.

Continued on LIC9099-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 59-AS-20260713084241
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ROSELEAF OROVILLE
FACILITY NUMBER: 045002773
VISIT DATE: 08/27/2026
NARRATIVE
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Facility is malodorous. - SUBSTANTIATED

It was reported that facility smells like urine.

On 08/062026 LPA toured the facility and observed the facility to be malodorous.

This allegation is substantiated.

Housekeeping services are inadequate. - SUBSTANTIATED

It was reported that the facility does not have a housekeeper.

On 07/16/2026 LPA toured the facility and found the common areas and resident rooms to be generally clean.

LPA reviewed a NOC cleaning log for common areas which states that all areas are to be cleaned, swept and mopped. LPA reviewed pages from a Housekeeping Binder that outlines which resident rooms are required to be cleaned on each day of the week.

During staff interviews it was learned that during the period after the housekeeper left the AM and PM shift completed light cleaning and the NOC shift completed deep cleaning duties.

Executive Director stated that the housekeeper left employment on June 17, 2026. The facility implemented a cleaning schedule for each shift for care givers to follow. NOC is the slower shift so everyone is responsible for cleaning a certain area. Especially in residents’ rooms if they are smelly or dirty. Kitchen and maintenance staff are assisting. ED stated the facility had just hired a new housekeeper but they had not yet started.

LPA confirmed that a new housekeeper was hired and started on 07/17/2026 and left employment on 08/24/2026. On 08/24/026 LPA was notified that the new housekeeper has left employment with the facility, currently the facility does not have a housekeeper. The current staffing level does not support staff being tasked to clean the facility effectively and also complete their care duties.

It was determined that the facility did not have a housekeeper for approx. 5 weeks. As of 08/24/2026 the facility again does not have a house keeper on staff. This allegation is substantiated.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. Exit interview was conducted and the report was provided to Executive Director Grace Hawkins.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 59-AS-20260713084241
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ROSELEAF OROVILLE
FACILITY NUMBER: 045002773
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/10/2026
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:
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The licensee agrees to update current call ou and holiday expectations for staff. In addition licensee shall implement this new policy in staff monthy training.
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Based on document review and interviews it was determined that the facility did not have enough staff on July 5, 2026. This poses a potential health, safety, and personal rights risk to residents in care.
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Licensee agrees to submit new policy and staff training sign in sheet to LPA as proof of correction.
Type B
09/10/2026
Section Cited
CCR
87219(f)
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87219(f) Planned Activities (f) In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities. This requirement was not met as evidenced by:
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The licensee agrees to hire a full time activities director who will fulfill that rle only.
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Based on document review and interviews it was determined that the facility did not have an activities director for a period of six weeks. This poses a potential health, safety, and personal rights risk to residents in care.
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Licensee has already hired an activities director. Licensee shall submit proof of hire and list of full time activities to LPA as proof of correction.
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: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 59-AS-20260713084241
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ROSELEAF OROVILLE
FACILITY NUMBER: 045002773
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/10/2026
Section Cited
CCR
87625(b)(3)
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87625(b)(3) Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by:
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The licensee agrees to submit a plan to licensing regarding how they will ensure that the facility is not malodorous.
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Based on observation it was determined that the facility is malodorous. This poses a potential health, safety, and personal rights risk to residents in care.
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Licensee agrees to submit this plan to LPA as proof of correction.
Type B
09/10/2026
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:
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The licensee agrees to hire a permanant housekeeper for the facility.
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Based on interviews, observation, and document review the facility did not have a housekeeper for approx. 5 weeks. As of 08/24/2026 the facility again does not have a house keeper on staff. This poses a potential health, safety, and personal rights risk to residents in care.
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Licensee shall submit proof of hire to LPA as proof of correction.
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: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/13/2026 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 59-AS-20260713084241

FACILITY NAME:ROSELEAF OROVILLEFACILITY NUMBER:
045002773
ADMINISTRATOR:HAWKINS, GRACEFACILITY TYPE:
740
ADDRESS:1900 20TH STTELEPHONE:
(530) 538-8200
CITY:OROVILLESTATE:CAZIP CODE:
95965
CAPACITY:60CENSUS: DATE:
08/27/2026
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Grace Hawkins - executive directorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Resident rooms are not cooled to meet Title 22 temperature requirements. - UNSUBSTANTIATED

INVESTIGATION FINDINGS:
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08/27/2026 10:30 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to deliver the results of a complaint investigation. LPA met with administrator Grace Hawkins and explained the purpose of the visit.

During the course of the investigation LPA toured the facility, conducted interviews and reviewed documents.

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 59-AS-20260713084241
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ROSELEAF OROVILLE
FACILITY NUMBER: 045002773
VISIT DATE: 08/27/2026
NARRATIVE
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Resident rooms are not cooled to meet Title 22 temperature requirements.- UNSUBSTANTIATED

On 07/16/2026 LPA toured the facility and saw large swamp coolers in three hallways, thermal curtains hung in the lower floor coffee area, large, vented air conditioning units in the lower and upper floor common areas, and individual vented air conditioning units in some resident rooms. LPA took temperature readings and found the lower hallway rooms varied between 72 and 76 degrees and the upper hallways rooms ranged between 70 and 76 degrees.

Staff interviews revealed that the room temperatures are better than they have been but some rooms are warmer than others.

ED stated the facility had installed curtains to all sun exposed windows in the common areas. We have been trying to lower the temperatures in the hallways to eliminate a warm draft going into resident rooms. The facility has installed three more swamp coolers and two rented ac units in the lower and upper common areas.

It was determined that the facility has taken prudent steps to ensuring that the facility temperatures are within Title 22 requirements. Room temperatures are measuring within Title 22 requirements. This allegation is unsubstantiated.

No deficiencies. An exit interview was conducted, and a copy of the report was provided to administrator Grace Hawkins.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7