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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
045002775
Report Date:
03/05/2024
Date Signed:
03/05/2024 02:28:44 PM
Document Has Been Signed on
03/05/2024 02:28 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
SACRAMENTO NORTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
ROSELEAF GARDENS
FACILITY NUMBER:
045002775
ADMINISTRATOR:
BINGHAM, DIANIA
FACILITY TYPE:
740
ADDRESS:
2770 SIERRA LADERA
TELEPHONE:
(530) 895-0800
CITY:
CHICO
STATE:
CA
ZIP CODE:
95928
CAPACITY:
56
CENSUS:
36
DATE:
03/05/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
08:20 AM
MET WITH:
Administrator- Stacy Baxter
TIME COMPLETED:
02:45 PM
NARRATIVE
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On 03/05/2024, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Facility Administrator, Stacy Baxter and explained the purpose of the visit.
LPA Boyles and Administrator toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, and common restrooms. LPA observed the bedrooms a majority of the rooms of the 8 wings of the facility to have all the required furnishings. However, LPA observed one room in the 800 wing to a bucket with urine. LPA observed the facility to not be odor free throughout the facility but was clean. LPA observed the bathrooms to have odor and one to not be in good repair. Of the bathrooms toured, one of eight (8) did not have a working bathtub. LPA observed the water temperature to be above the required temperature in two (2) of the eight (8) resident. LPA observed a resident room to have oxygen but no posting outside the resident room to indicate oxygen is in use. Facility has a 2-day perishable and a 7-day non-perishable amount of food. However, the kitchen was disorganized, cluttered and not clean.
LPA observed several fire extinguishers, fire detectors, and carbon monoxide detectors throughout the facility last which was serviced in January of 2024. LPA observed the first aid kit to be complete and ready for use. LPA observed the fire system to have been last serviced in February 2024. LPA observed medications and toxic chemicals to be locked and inaccessible to residents.
LPA reviewed a total of six (6) residents' files and six (6) staff files. Of the six resident files reviewed, two of three residents had bed rails but did not have medical orders for the postural supports found in the resident file. Of the six resident files reviewed, LPA observed all of the required documentation. LPA reviewed six (6) staff files, all were missing a TB test and documentation of first aid training.
Several topics were discussed.
SUPERVISOR'S NAME:
Lauren Crocker
TELEPHONE:
(916) 261-4966
LICENSING EVALUATOR NAME:
Jaynae Boyles
TELEPHONE:
(916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE:
03/05/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION 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 GARDENS
FACILITY NUMBER:
045002775
VISIT DATE:
03/05/2024
NARRATIVE
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California Code of Regulations, (Title 22), is being cited on the attached LIC809D. Appeal rights were provided. An exit interview was conducted. A copy of the report was provided to administrator.
SUPERVISOR'S NAME:
Lauren Crocker
TELEPHONE:
(916) 261-4966
LICENSING EVALUATOR NAME:
Jaynae Boyles
TELEPHONE:
(916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE:
03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/05/2024
LIC809
(FAS) - (06/04)
Page:
8
of
8
Document Has Been Signed on
03/05/2024 02:28 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
SACRAMENTO NORTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
ROSELEAF GARDENS
FACILITY NUMBER:
045002775
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in two out of eight bathrooms in which the water was tested it was above the required 120 degree maximum which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
03/06/2024
Plan of Correction
1
2
3
4
The administrator will create and implement a process to check the water tempeture to ensure that it remains within regualtion. Administrator will share this plan with the LPA.
Type A
Section Cited
CCR
87303(f)(1)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (1) Solid waste shall be stored, located and disposed of in a manner that will not permit the transmission of a communicable disease or of odors, create a nuisance, provide a breeding place or food source for insects or rodents.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on observation, the licensee did not comply with the section cited above in that urine was found in a bucket in the room of a resident with dementia which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
03/06/2024
Plan of Correction
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2
3
4
Administrator will develop and implement a plan to ensure that all solid waste is disposed of appropriately. Administrator will share this plan with the LPA.
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
TELEPHONE:
(916) 261-4966
LICENSING EVALUATOR NAME:
Jaynae Boyles
TELEPHONE:
(916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE:
03/05/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/05/2024
LIC809
(FAS) - (06/04)
Page:
2
of
8
Document Has Been Signed on
03/05/2024 02:28 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
SACRAMENTO NORTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
ROSELEAF GARDENS
FACILITY NUMBER:
045002775
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in six of six staff files reviewed did not have the above requirement documented in the file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/12/2024
Plan of Correction
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2
3
4
Administrator will develop and implement a plan to ensure that the above regulation completed before the employee begins employment. Adminstrator will share this plan the the LPA.
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
TELEPHONE:
(916) 261-4966
LICENSING EVALUATOR NAME:
Jaynae Boyles
TELEPHONE:
(916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE:
03/05/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/05/2024
LIC809
(FAS) - (06/04)
Page:
3
of
8
Document Has Been Signed on
03/05/2024 02:28 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
SACRAMENTO NORTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
ROSELEAF GARDENS
FACILITY NUMBER:
045002775
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based onobservation, the licensee did not comply with the section cited above in one of the eight bathtubs observed was not in working order which poses/posed a potential health, safety or personal righ ts risk to persons in care.
POC Due Date:
03/12/2024
Plan of Correction
1
2
3
4
Administrator will repair the broken bathtub and inform the LPA when complete.
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in six of the six staff files reviewed did not have the above mentioned requirement within the file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/12/2024
Plan of Correction
1
2
3
4
Administrator will develop and implement a plan to ensure that all staff are first aid trained before begining employment. Administrator will share this plan with the LPA.
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
TELEPHONE:
(916) 261-4966
LICENSING EVALUATOR NAME:
Jaynae Boyles
TELEPHONE:
(916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE:
03/05/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/05/2024
LIC809
(FAS) - (06/04)
Page:
4
of
8
Document Has Been Signed on
03/05/2024 02:28 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
SACRAMENTO NORTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
ROSELEAF GARDENS
FACILITY NUMBER:
045002775
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in no fire drills were conducted in the last 12 months, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/12/2024
Plan of Correction
1
2
3
4
Administrator will develop and implement a plan to ensure that fire drills are conducted as required. Administrator will share this plan with the LPA
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation record review, the licensee did not comply with the section cited above in two of the three files reviewed of residents to have observed to have bed rails did not have an medical order in the file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/12/2024
Plan of Correction
1
2
3
4
Administrator will develop and implenet a plan to ensure that all residents with bed rails have a medical order in the file. Admin will share this plan with the LPA.
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
TELEPHONE:
(916) 261-4966
LICENSING EVALUATOR NAME:
Jaynae Boyles
TELEPHONE:
(916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE:
03/05/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/05/2024
LIC809
(FAS) - (06/04)
Page:
5
of
8
Document Has Been Signed on
03/05/2024 02:28 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
SACRAMENTO NORTH ASC
,
9835 GOETHE ROAD, SUITE 100
SACRAMENTO
,
CA
95827
FACILITY NAME:
ROSELEAF GARDENS
FACILITY NUMBER:
045002775
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/05/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87618(b)(3)(B)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that a resident who had oxygen in their room but did not have the "No Smoking- Oxygen in Use" sign posted which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/12/2024
Plan of Correction
1
2
3
4
Administrator will ensure that all residents who are in need of Oxygen have the apporpriate postings outside the room to ensure the safety of residents in care. Adminstrator will share this information with the LPA
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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
TELEPHONE:
(916) 261-4966
LICENSING EVALUATOR NAME:
Jaynae Boyles
TELEPHONE:
(916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE:
03/05/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/05/2024
LIC809
(FAS) - (06/04)
Page:
6
of
8