045002773-9-24-2026-59-AS-LCRR-DY9SQ6-20260925140409

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045002773
Report Date: 09/24/2026
Date Signed: 09/24/2026 03:59:45 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
08/03/2026 and conducted by Evaluator Rebecca Knight

COMPLAINT CONTROL NUMBER: 59-AS-20260803143957

FACILITY NAME:	ROSELEAF OROVILLE		FACILITY NUMBER:	045002773
ADMINISTRATOR:	HAWKINS, GRACE		FACILITY TYPE:	740
ADDRESS:	1900 20TH ST		TELEPHONE:	(530) 538-8200
CITY:	OROVILLE	STATE: CA	ZIP CODE:	95965
CAPACITY:	60	CENSUS: 25	DATE:	09/24/2026
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Grace Hawkins - executive director		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff are smoking marijuana on facility grounds. - SUBSTANTIATED
Staff are not dispensing medication as ordered by physician. - SUBSTANTIATED
Cleaning supplies left accessible to residents. – SUBSTANTIATED

INVESTIGATION FINDINGS:

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09/24/2026 01:40 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to deliver the result of a complaint investigation. LPA met with executive director Grace Hawkins and explained the purpose of the visit.

During the course of the investigation LPA conducted interviews, toured the facility 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: 09/24/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026

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 8

Control Number 59-AS-20260803143957

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: 09/24/2026

NARRATIVE

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pg. 2

Staff are smoking marijuana on facility grounds. - SUBSTANTIATED

It was reported that staff were seen smoking marijuana on the patio and smelled of marijuana.

ED stated during an internal investigation three staff admitted smoking marijuana on facility grounds. All three staff have been terminated.

This allegation is substantiated.

Staff are not dispensing medication as ordered by physician. - SUBSTANTIATED

It was reported that a resident who has cellulitis is not being dispensed their prescribed medication to treat cellulitis.

LPA reviewed R1’s LIC602 Physicians Report states that R1 is unable to store or administer their own medications. Care notes for R1 report on 05/19/2026 zinc oxide was dispensed. 06/07/2026 R1 refused all medications. 07/03/2026 R1 allowed staff to administer zinc oxide cream. 07/08/2026 R1 refused all medications. R1’s medication administration record (MAR) for July 2026 does not include this medication. 08/01/2026 – 08/04/2026 MAR shows this medication was not scheduled to be dispensed to R1. On 08/05/2026 and 08/06/2026 it is documented that R1 refused this medication. The MAR reports that R1 refused this medication for 12 of 18 days from the dates of 09/01/2026 through 09/18/2026.

During staff interviews it was learned that only the med techs are allowed to dispense the zinc cream. Staff try to dispense zinc cream to R1 but R1 does refuse. Sometimes R1 will allow hospice to dispense the zinc cream.

ED stated staff should be dispensing zinc cream to R1 unless R1 refuses.

It was determined that although R1 does sometimes refuse to allow staff to dispense their prescribed ointment it is still the licensee’s responsibility to ensure that R1 is successfully dispensed all prescribed medications. This allegation is substantiated.

Continued on LIC9099-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 59-AS-20260803143957

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: 09/24/2026

NARRATIVE

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pg 3

Cleaning supplies left accessible to residents. - SUBSTANTIATED

It was reported that laundry room was propped open and there was an open laundry soap on the counter with no staff around.

During a tour of the facility on 08/27/2026 LPA observed the laundry room door to be unlocked and accessible.

During staff interviews it was learned that the door to the laundry room had often been left open but now care staff have to ask a med tech to unlock the door for them.

ED stated the facility has repaired the lock on the laundry room door.

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: 09/24/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 8

Control Number 59-AS-20260803143957

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: 09/24/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/08/2026 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	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:	1 2 3 4 5 6 7	The licensee agrees to conduct staff training pertaining to the requirement that staff are not under the influence of drugs or alcohol while on facility grounds.
	8 9 10 11 12 13 14	Based on interviews the licensee failed to ensure that staff were not smoking marijuana on facility grounds. This poses an immediate health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14	Licensee shall submit training content and staff sign in sheet to LPA as proof of correction.
Type A 10/08/2026 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465(a)(4) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The licensee agrees to conduct staff training on the requirement to dispense all prescribed medications to residents. In addition the licensee shall develop a plan specific to ensuring that Resident 1 zinc ointment is dispensed.
	8 9 10 11 12 13 14	Based on interviews and document review the licensee failed to ensure that 1 of 25 residents was dispensed their zinc ointment as prescribed by their physician.	8 9 10 11 12 13 14	Licensee shall submit training content, staff sign in sheet, and plan 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: 09/24/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 8

Control Number 59-AS-20260803143957

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: 09/24/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/08/2026 Section Cited CCR 87309(a)	1 2 3 4 5 6 7	87309(a) Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee shall repair lock on laundry room door.
	8 9 10 11 12 13 14	Based on LPA observation the laundry room door was unlocked and accessible to residents.	8 9 10 11 12 13 14	LPA confirmed that lock has been repaired during the visit.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 09/24/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 8

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
08/03/2026 and conducted by Evaluator Rebecca Knight

COMPLAINT CONTROL NUMBER: 59-AS-20260803143957

FACILITY NAME:	ROSELEAF OROVILLE		FACILITY NUMBER:	045002773
ADMINISTRATOR:	HAWKINS, GRACE		FACILITY TYPE:	740
ADDRESS:	1900 20TH ST		TELEPHONE:	(530) 538-8200
CITY:	OROVILLE	STATE:CA	ZIP CODE:	95965
CAPACITY:	60	CENSUS:	DATE:	09/24/2026
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Grace Hawkins - executive director		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Residents’ toileting needs are not being met. - UNSUBSTANTIATED
Kitchen left accessible to residents with no staff present. - UNSUBSTANTIATED
Inadequate staffing resulting in lack of care and supervision. - UNSUBSTANTIATED

INVESTIGATION FINDINGS:

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09/24/2026 ??:00 PM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to deliver the result of a complaint investigation. LPA met with executive director Grace Hawkins and explained the purpose of the visit.

During the course of the investigation LPA conducted interviews, toured the facility 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: 09/24/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026

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 8

Control Number 59-AS-20260803143957

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: 09/24/2026

NARRATIVE

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Residents’ toileting needs are not being met.- UNSUBSTANTIATED

It was reported that residents are not being changed timely.

LPA reviewed care notes for R1 for the month of September 2026. Throughout the notes R1 refuses care, refuses briefs, allows staff to assist them with toileting some days and not on other days.

During staff interviews it was learned that residents are toileted every 2 hours and if they don’t toilet their brief is changed every two hours. Staff reports that Resident 1 (R1) mostly refuses briefs and toileting assistance. Staff reports that they offer R1 toileting assistance and briefs every two hours.

ED stated about 20 residents require toileting assistance but some also toilet themselves and wearing a brief is an extra precaution.

It was determined that staff provide appropriate toileting assistance to all residents. One resident intermittently refuses toileting assistance from staff; staff cannot force a resident to accept toileting assistance. This allegation is unsubstantiated.

Kitchen left accessible to residents with no staff present.- UNSUBSTANTIATED

It was reported that kitchen door was propped open and no staff were in the kitchen.

On visits to the facility on dates of 08/06/2026 and 08/27/2026 LPA observed the kitchen door to be secured.

Staff interviews revealed that the kitchen door is only propped open when staff are serving meals.

This allegation is unsubstantiated.

Continued on LIC9099-C

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 59-AS-20260803143957

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: 09/24/2026

NARRATIVE

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pg 3
Inadequate staffing resulting in lack of care and supervision. - UNSUBSTANTIATED

It was reported that there have only been 1 care staff and 1 med tech on staff most of the time.

This complaint was made on August 03, 2026. LPA reviewed staffing schedule for the month of July 2026 which reports adequate staffing all month except for the following days: 07/02/2026 PM shift 1 MT and 1 CG, 07/05/2026 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, 07/31/2026 all shifts 1 MT and 1 CG. LPA has already issued a citation on complaint #59-AS-20260713084241 related to Inadequate staffing over July Fourth holiday weekend, specific to 07/05/2026.

Staff interviews revealed that there are 2 care givers and 1 med tech on each shift.

ED stated there are 1 med tech and 2 care staff for all shifts including NOC.

It was determined that a staffing citation was already issued for the time frame related to the new complaint. No deficiency will be issued related to the new complaint.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to Executive Director Grace Hawkins.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026

LIC9099 (FAS) - (06/04)

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