Roseleaf Senior Care

Type of visit: Case Management - Legal/Non-compliance

On 04/11/23 Alycia Berryman, Regional Manager, Lauren Crocker, Licensing Program Manager, Donna Gurriere and Rebecca Knight, Licensing Program Analysts, Jaqueline Juarez, Audits Section Manager and Jessica Chen, Auditor held a non-compliance conference with Rajesh Rao, Sridhar Nagunuri, Sabi Bains, Ramaprasad Samudrala and Diania Bingham. The meeting was held via Teams. The following information was discussed: On 07/11/22 a complaint was received and one of the allegations was that the facility was having financial issues. A request was made to the department’s audit unit to review all four facilities and their financial issues. A solvency audit was conducted during the months of July 2021 through August 2022. On 01/04/23 and 01/26/23, the audit unit reported the following: Objective 1) To determine if the licensee has an adequate financial plan in compliance with CCR, Title 22, Section 87213 FINANCES, that assures sufficient resources to meet operating expenses for care and supervision of residents. Finding 1) The licensee does not have an adequate financial plan to ensure residents’ care and supervision won’t be interrupted. Finding 2): Inadequate Liability Insurance coverage. Finding 3): Accountability of Licensee Governing Body Regulation – The late utility payments, insufficient funds & overdraft fees, inadequate general liability coverage noted indicates the licensee failed to exercise general supervision over the affairs of the licensed facilities. Objective 2). To determine if the licensee is in good financial position and generates sufficient income to cover the operating expenses and meet short term obligations/liabilities Finding 1): Overall, Roseleaf Oroville is not in a good financial standing due to negative incomes, falling behind on some large payments, and currently has negative equity. 1) The licensee will be cited for the following: a. CCR Title 22, Division 6, Section 87213 Finances; b. CCR Title 22, Division 6, Section 87205 Accountability; and c. Health and Safety Code, Section 1569.605 Liability Insurance. 2) Licensee shall be on financial monitoring for two (2) quarters or until it is evident a sound financial plan is in place and sustained Specifically, the licensee is to provide monthly utility bills and mortgage statements to the licensing agency to show the utility expenses are paid in-full by the noted due dates on the bills to avoid additional fees and disconnections of services; Licensee shall prepare and submit quarterly Profit and Loss Statement, with supporting documents; Specifically, revenue to be supported by the rent roll and bank statements showing funds have been deposited. Expenses to be supported by actual invoices and payments made; First quarter documents are to be submitted by the end of month following quarter end. 3) Licensee shall carry adequate general liability insurance required by law that each RCFE to be covered $1 million each occurrence and $3 million aggregate annually. A blanket coverage covering multiple facilities and businesses is not sufficient and not accepted. Per today's meeting the requested documents shall be sent to Rebecca Knight, Licensing Program Analyst by 04/17/23. The requested audits documents shall be sent to the Audits Unit by 07/25/23. Based on investigation 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), is 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 date; civil penalties may be assessed.the state’s words, verbatim · CDSS document, Apr 11, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87213 · Plan of correction due date: Apr 17, 2023

Finances - The licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that assures sufficient resources to meet operating costs for care of residents; shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency… The licensee did not ensure that there were sufficient resources to meet operating costs for the care of residents.the state’s words, verbatim · CDSS document, Apr 11, 2023

Plan of correction: The licensee agrees to follow the recommendations that are indicated in the report.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87205(a)(b) · Plan of correction due date: Apr 17, 2023

Accountability of Licensee Governing Body - The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability. The licensees did not exercise general supervision over the affairs of their licensed facilities.the state’s words, verbatim · CDSS document, Apr 11, 2023

Plan of correction: The licensee agrees to follow the recommendations that are indicated in the report.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.605 · Plan of correction due date: Apr 17, 2023

Liability Insurance - On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. The licensee did not maintain liability insurance per the Health and Safety Code.the state’s words, verbatim · CDSS document, Apr 11, 2023

Plan of correction: The licensee agrees to follow the recommendations that are indicated in the report.

Type of visit: Required - 1 Year

02/23/2023 12:30 AM, Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Lisa Sapp - Interim Executive Director and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed 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: N-95 Mask and gloves. Additionally, LPA was screened by facility staff. The facility closed its doors end of November 2022. Remaining 8 residents moved to Roseleaf Gardens. LPA toured the facility to complete the inspection, there were no residents in care and the facility was not in operation at the time of this inspection. No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report was provided to Lisa Sapp- Interim Executive Director.the state’s words, verbatim · CDSS document, Feb 23, 2023

Allegation investigated: Facility did not have the food supply required by the regulations Facility staff are not able to serve residents food listed on the menu

LPA Hiratsuka, conducted this unannounced complaint visit. LPA wore a surgical mask during visit and observed all staff wearing surgical masks. LPA inspected the food supply. Title 22 Regulations 87555(b)(26) General Food Service Requirements: Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. LPA observed one half loaf of bread, 4 2lb cans of fruit, 6 15.3 oz cans of corn, one package of hamburger buns, cereal, some snack foods, and the rest was dry ingredients that could not be used by themselves as food. There was about 15 small sweet potatoes and about 14 oranges and eight bananas. This does not meet the requirements. There is not enough nonperishable food for three meals a day for seven days for eight residents. LPA was informed during this visit there are residents moving out today. LPA was informed prior to this visit the licensee gave 60 day notice of closure and residents are moving out because of that. Substantiated Title 22 Regulations 87555(b)(6) General Food Service Requirements: In facilities for sixteen (16) persons or more, menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days. Facilities licensed for less than sixteen (16) residents shall maintain a sample menu in their file. Menus shall be made available for review by the residents or their designated representatives and the licensing agency upon request. LPA requested a copy of the menu and was told one is not available. The cook makes meals based on the available ingredients. Because there is no menu the facility does not have proof there is enough ingredients to make meals for the residents and meet any diets prescribed by doctor. Based on all the above, the allegations are substantiated. Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code. Failure to correct shall result in civil penalties.the state’s words, verbatim · CDSS document, Nov 9, 2022 · control 25-AS-20221107093224

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(26) · Plan of correction due date: Nov 10, 2022

General Food Service Requirements. The following food service requirements shall apply: Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. Based on observation Licensee failed this by: LPA observed 4 2lb cans of fruit, cereal, one package of hamburger buns, a partial loaf of bread, some fruits and vegetables, and snack food. This does not mee the nonperishable food supply requirement. This is an immediate health and safety risk to residents.the state’s words, verbatim · CDSS document, Nov 9, 2022

Plan of correction: By 11/10/2022, the facility shall have a seven day nonperishable food supply and shall maintain it based on the number of residents until the facility closes.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(6) · Plan of correction due date: Nov 18, 2022

General Food Service Requirements. In facilities for sixteen (16) persons or more, menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days. Licensee failed this based on observation. The facility does not have a menu for LPA to review and therefore does not have proof they have enough ingredients for the meals that are prepared. This is an immediate health and safety risk to residents.the state’s words, verbatim · CDSS document, Nov 9, 2022

Plan of correction: By 11/10/2022, the licensee shall come up with a set menu and the food supply shall meet the menu.

Type of visit: Office

An office meeting was held on 9/7/2022, via Microsoft Teams to discuss topics listed in this report. The purpose of today's meeting is to follow up on the meeting previously held on 7/22/2022. The following Licensing staff were present: Regional Manager (RM) Alycia Berryman, Licensing Program Manager (LPM) Laura Munoz, and Licensing Program Analyst (LPA) Sabrina Calzada. The following representatives present: Administrator Amber Farmer (Roseleaf Oroville), Administrator Audre Smith (Roseleaf Gardens), Administrator Samantha Guarino (Roseleaf Senior Care), Stephen Ratliff Chief Operating Officer, CEO/Licensee Sridhar Naguynuri and Attorney Joel S. Goldman. The following topics were discussed during today's meeting: Physical plant: Staffing levels to meet the needs of residents in care and considerations for determining how many staff are needed. Administrators provided specific staffing levels and resident census Overall operations of facilities - role of consultant, increased staff meetings/training Covid outbreak - currently all facilities are cleared through local public health. Discussed Infection Control Plan/visitation and consulting local public health for guidance. Exit interview with Administrator. A copy of this report will be provided to Administrator. A copy will be signed and returned to CCL via e-mail.the state’s words, verbatim · CDSS document, Sep 7, 2022

Type of visit: Office

An office meeting was held on 7/22/2022, via Microsoft Teams to discuss topics listed in this report. The delay in getting report completed same day was a result of the CCLD server going down. The following Licensing staff were present: Regional Manager (RM) Alycia Berryman, Licensing Program Manager (LPM) Laura Munoz, and Licensing Program Analyst (LPA) Jaclyn Avila The following representatives present: Residential Care Coordinator Amber Farmer (Roseleaf Oroville), Administrator Audre Smith (Roseleaf Gardens), Administrator Samantha Guarino (Roseleaf Senior Care), Stephen Ratliff Chief Operating Officer, CEO/Licensee Sridhar Naguynuri and Attorney Joel S. Goldman The following topics were covered during today's meeting: · Citations issued to Roseleaf Oroville on 7/15/2022 · Physical plant: Roseleaf Oroville- malfunctioning Fire alarm system, inoperable air conditioning system, inoperable water heater, call system · Staffing levels to meet the needs of residents in care and considerations for determining how many staff are needed · Facility Administrator vacancies · Overall operation of all 3 residential facilities Documents requested and due by 7/29/2022: New Administrator documents Letter/recommendation from Fire system vendor Voltage Specialist regarding the condition of the fire system Letter from Fire Marshal Chris Boyd with Cal Fire regarding recommendation for the fire system. Letter from ACCO Engineered Systems regarding recommendation for air conditioner A copy of this report will be provided to Licensee Sridhar Naguynuril via e-mail. A copy will be signed and returned to CCL via e-mail.the state’s words, verbatim · CDSS document, Jul 22, 2022

Type of visit: Office

An informal conference was conducted today via Microsoft Teams Platform. The purpose of this informal conference meeting is to discuss the inability to remain in substantial compliance with the regulations. Present in the meeting is Regional Manager Alycia Berryman, Licensing Program Manager Laura Munoz, Licensing Program Analyst Jaclyn Avila, Licensee Raj Rao, Chief of Operations Stephen Ratliff, Audre Smith, Dave Curtis interim CEO of Peer Services and Administrator Samantha Guarino. The informal conference process was explained during this meeting. The facility has been cited 11 times in the last year. The facility was cited for the following issues: personal rights, staffing, incontinence care, activities, dementia care, etc. The facility was cited for 8 Type A citations, and 3 Type B citations. Three complaints were filed against the facility. Issues discussed during the meeting were: · Staffing issues and training · Food Service · Housekeeping · Activities Cont'd on LIC 809-C · Activities · Medications · Providing ADLs · Licensee/Administrator accountability · Transition as Peer Services separates as Licensee/Management · Ensuring all staff regardless of position are fingerprint cleared and associated The facility has stated they will do the following to achieve continued and substantial compliance: · Increase the amount of training each staff receives · Create policies and procedures to ensure staff are meeting needs of residents · Maintain at least two direct care staff one of which is also a med tech · Increase oversite of facility operations The following Forms are due by June 10th, 2022 and are to be submitted to LPA LIC 308 The following Forms are due by June 30th, 2022 and are to be submitted to LPA Infection Control Plan The following Forms are due by July 8th, 2022 and are to be submitted to LPA LIC 500 Personnel report Resident Roster LIC 9020 Activities Schedule Medication Policy and Auditing System LIC 309 and Organizational flow chart Copy of this report will be e-mailed to the Licensee for Signature and a signed copy will be returned same day to LPA.the state’s words, verbatim · CDSS document, Jun 8, 2022

Type of visit: Case Management - Other

On 4/22/2022 at about 11:15AM, Community Care Licensing (CCL) Licensing Program Analyst (LPA) Jaclyn Avila, Licensing Program Manager (LPM) Laura Munoz, and Regional Manager (RM) Alycia Berryman arrived at the facility unannounced to conduct a case management visit regarding facility compliance, CCL met with Administrator Samantha Guarino and Executive Director Eric Perry and explained the purpose of the visit. Prior to initiating the visit, CCL 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. CCL ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 and Surgical masks. CCL met with Administrator Samantha Guarino in the facility's admin office. CCL interviewed the Administrator regarding staffing numbers, Administrator duties and resident needs. CCL toured the facility with facility designee Eric Perry. This facility currently has 6 resident's in care. 2 of 6 residents are receiving hospice care services. CCL staff observed 2 caregivers, 1 cook and the Administrator on duty during today's visit. In addition, CCL staff reviewed resident records while at the facility. Based on interviews, observations and records review, the facility is currently understaffed to meet the needs of residents in care. It was learned that shifts run 12 hours and there is 1 staff working during the overnight shift. CCL observed 2 (R1 and R2) of 6 residents who are documented 2 person assists as well as 1 (R3) of 6 resident's who are documented as a fall risk. During interviews with staff, staff indicated they would not be able to independently assist R3 if R3 fell. With the information above, the facility is being cited today per CCR, Title 2, Section 87411(a) as it has been identified that the facility will need additional staffing to meet the needs of the current residents in care. Citations issued on the attached LIC809D. Exit interview and copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 22, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Apr 29, 2022

87411(a) Personnel Requirements. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement has not been met as evidenced by: Based on documentation, interviews and observations, the facility has 3 of 6 people that require 2 person assist to meet care needs. The facility only staffs overnight shift with 1 staff which posses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 22, 2022

Plan of correction: The licensee shall....submit a plan to CCL by 4/29/22 on hiring and scheduling to have 2 caregivers on 24 hrs/day. 1 caregiver can have dual role as Med Tech. Licensee agrees to submit a plan as how residents needs will be met until they are able to staff 2 caregivers.

Type of visit: Required - 1 Year

On 4/13/2022 at about 2:00 PM Licensing Program Analysts (LPA) Jaclyn Avila and David Loperena arrived at the facility unannounced to conduct a required - 1 - year annual regarding infection control, LPAs met with Staff Anna McFarland and Executive Director Eric Perry and explained the purpose of the visit. Prior to initiating the visit, LPAs 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. LPAs toured the facility with med tech Anna McFarland to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident rooms, common bathrooms, dining room, visiting area and storage areas. At approximately 2:15 PM, LPAs and MT McFarland observed room #180. LPA observed the carpet to be soiled and stained. LPA observed food crumbs and a breakfast sausage link underneath the residents bed along with other unidentifiable debris. In the attached bathroom, personal hygiene items were located and accessible on the bathroom sink. LPA reviewed the Residents Physicians report and found the doctor determined the personal hygiene items pose a risk to resident if not supervised. Resident was alone at time of inspection. At approximately 2:26 PM, the kitchen was toured and containers with food were observed to not be labeled or opened and packaged. ED agreed to have the food audited today and kitchen disinfected today. The following deficiencies were cited per Title 22 of the California Code of Regulation see LIC 809D. 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.the state’s words, verbatim · CDSS document, Apr 13, 2022

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff do not assist residents with their incontinence needs

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: Staff do not assist residents with their incontinence needs Cont'd on 9099-C Substantiated This Department reviewed two resident files and found both residents were incontinent. During staff interviews, staff stated due to resident behaviors and lack of training with those behaviors, residents did not have their briefs changed. This department reviewed the “reported care report” and “Observations” which were authored by staff submitted to CCLD by the facility. This department observed that R1 last received incontinent care on 12/19/21 at 9:21 PM. On 12/20/21 at 05:18 AM, MT documents, “(R1) SLEPT MOST OF THE NIGHT I TRIED TO HELP R1 CHANGE BUT NO LUCK, AM SHIFT WILL BE INFORM AND WILL TRY.” The next entry is on 12/20/21 at 1203 PM which states, “Resident has refused care all day, but this writer did manage to change Resident's bedding. MT will try to later change Resident's brief.” The subsequent 3 entries are similar. Its not documented until 12/21/21 at 2:17 PM that R1 was changed, “Resident's bedding was fully changed and socks, pants and briefs as well.” However, on 12/21/21 at 11:33 PM its documented, “Resident had refused to allow PM shift staff to provide care despite being visibly saturated in urine. During shift change Med Tech was able to change resident and RA was able to provide bedding change during that time as well.” On the Recorded Care Chart for R2 (Resident 2) observed on 12/21/21 at 11:04PM, incontinence care was completed. Incontinence care does not show completed again until 12/22/21 at 2:31 PM. The reasons listed by staff for not having completed incontinence care state, “Resident refused attempt to provide care, Resident refused becoming agitated and aggressive, etc..” 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. Only administrative staff were able to provide ways that they can redirect to provide incontinence care. Care giving staff reported they are not trained in providing incontinence care to combative residents although Executive Director provided demonstrations with R1. 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.the state’s words, verbatim · CDSS document, Apr 8, 2022 · control 25-AS-20211118143230

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87625(b)(3) · Plan of correction due date: Apr 9, 2022

87625(b)(3) Managed Incontinence- In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry This requirement is not met as evidenced by: Based upon record review and interview the Licensee failed to ensure 2 of 2 residents were kept clean and dry. This poses a potential Health, Safety and/or Personal Rights risk to clients in carethe state’s words, verbatim · CDSS document, Apr 8, 2022

Plan of correction: Licensee agrees to provide training on incontinence care and resident centered care. Licensee will provide training plans by 4/9/22

Allegation investigated: Facility is not reporting incidents to Community Care Licensing. Residents are not receiving medical care timely. Resident received an injury while in care.

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 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.the state’s words, verbatim · CDSS document, Apr 8, 2022 · control 25-AS-20211021082114

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Apr 9, 2022

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 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.the state’s words, verbatim · CDSS document, Apr 8, 2022

Plan of correction: 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

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Apr 11, 2022

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 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.the state’s words, verbatim · CDSS document, Apr 8, 2022

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Apr 15, 2022

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 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 carethe state’s words, verbatim · CDSS document, Apr 8, 2022

Plan of correction: 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.

Allegation investigated: Residents are not getting needs met due to understaffing. The administrator is not often present at the facility. Activities are not provided.

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 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 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.the state’s words, verbatim · CDSS document, Apr 8, 2022 · control 25-AS-20211102083921

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87219(a) · Plan of correction due date: Apr 9, 2022

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: 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.the state’s words, verbatim · CDSS document, Apr 8, 2022

Plan of correction: 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.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Apr 9, 2022

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: 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.the state’s words, verbatim · CDSS document, Apr 8, 2022

Plan of correction: Licensee agrees to provide CCL with a plan by 4/9/2022 to ensure personnel will be sufficient in numbers and competent.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(h)(8) · Plan of correction due date: Apr 22, 2022

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. 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 carethe state’s words, verbatim · CDSS document, Apr 8, 2022

Plan of correction: Licensee cleared POC prior to today's visit. Licensee has hired a new administrator.

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Jacob Williams conducted a case management visit to the facility on today's date for the purpose of delivering an Order To Individual of Immediate Exclusion from all facilities and the Order to Licensee/Facility of Immediate Exclusion From Facility. 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: N-95 respirator. Additionally, LPA was screened by staff upon entering the facility. LPA met with current Executive Director, Eric Perry and explained the purpose of today's visit. Staff Pauline Willyard is excluded as a result related to this facility. LPA Williams handed the Order to Executive Director Facility of Immediate Exclusion From Facility letter to Eric Perry and explained that staff, Pauline Willyard is not allowed back at the facility. A copy of this report was provided to Administrator.the state’s words, verbatim · CDSS document, Feb 16, 2022

Type of visit: Case Management - Deficiencies

On 12/30/21 at 10:30 AM, Licensing Program Analyst (LPA) Jaclyn Avila conducted an unannounced case management visit concerning two incident reports that were submitted to Community Care Licensing (CCL) on 12/16/2021. LPA met with Executive Director (ED) Eric Perry and explained the purpose of the visit. Prior to initiating the visit, 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; contacted Roseleaf Senior Care and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: PAPR. LPA completed the facility screening questionnaire. The first of two incident reports submitted on 12/16/2021 detailed that on 12/15/2021 near dinner time. S1 (staff 1) was witnessed entering R1’s (Resident 1) room with the intent to administer prescribed medication. S1 requested S2 grab resident’s legs. S1 was witnessed holding R1’s wrists against R1’s chest then placing the medication in R1’s mouth via syringe. S1 was then witnessed placing S1’s hands over R1’s mouth. Executive Director (ED) upon being notified of the incident notified R1’s responsible party, Ombudsman and Community Care licensing. Per the incident report medical treatment was not needed and S1 was suspended. The second incident report submitted to CCL on 12/16/2021 detailed that on 12/15/2021 at about 8 PM, S1 was witnessed entering R2’s room with the intent to “change” R2. S1 was allegedly witness holding R2 by the thumbs and hands even after it was suggested a different method be used. S1 was allegedly witnessed stating to R2, “that’s why you’re here, this is your prison sentence.” ED upon being notified of the incident reported to S2’s responsible party, ombudsman and CCL. Per the incident report medical treatment was not needed and S1 was suspended. cont'd on 812-C This department investigated the incident which consisted of document review and interviews which revealed that on 12/15/2021, S1 held R1 down by pinning both wrists against R1’s chest. S1 did this to administer crushed medication into R1’s mouth that R1 often refuses. S1 later restrained R2, who had documented behaviors, in order to change R2. The facility investigated the incident and spoke with S1 who admitted to knowing S1’s actions were wrong. Per the facilities investigation S1 admitted to holding R1 to get R1 to take medication and admitted to holding R2 to change him. ED reported to the responsible parties, ombudsman and CCL as required. ED however did not report incident to law enforcement within 24 hours as required. ED called in the reportable incidents to the Chico Police Department on 12/30/21 during the CCL site visit. ED terminated S1 on 12/27/21. Both residents have memory care related conditions. The facility interviewed the residents shortly after the incident and neither resident could recall what occurred. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights provided. Report provided via e-mail.the state’s words, verbatim · CDSS document, Dec 30, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Dec 31, 2021

87468.2(a)(8)-Personal Rights-To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by: Interview and documentation. Licensee failed to protect 2 of 2 residents from physical abuse. This poses an immediate risk to residents in carethe state’s words, verbatim · CDSS document, Dec 30, 2021

Plan of correction: Licensee agrees to assigned all staff Relias training on resident rights by COB on 12/31/21 and will have staff complete the training by 1/14/2022. Licensee agrees to conduct an inservice training on Title 22 related regulations . Licensee will provide the plan for the inservice training by COB on 12/31/21.

Type of visit: Case Management - Incident

11/22/2021 11:00 AM Licensing Program Analyst (LPA) Rebecca Knight arrived at the facility unannounced to conduct a case managment investigation. LPA met with administrator Eric Perry 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; contacted administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask, gloves. The reason for the visit is an incident report that was received on 11/09/2021, in which it was reported that a staff person had slapped and threatened a resident. LPA requested copies of the following documents: Staff list with phone numbers, Resident's Physician's Report and admission agreement. More investigation and interviews are necessary. No deficiencies were cited during today's visit. An exit interview was conducted, and a copy of the report was emailed to administrator Eric Perry.the state’s words, verbatim · CDSS document, Nov 22, 2021

Type of visit: Case Management - Health Checks

On 8/1/21 at 10:00 AM, Licensing Program Analyst (LPA) Jaclyn Avila conducted an unannounced Case Management Health and Safety visit as directed by the department. LPA spoke with Executive Director Eric Perry by phone to announce the visit. LPA met with Eric and explained the reason for the visit. Prior to initiating the visit, 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: N-95 mask. Additionally, LPA self screened and temperature checked at the faciilty. LPA toured the facility inside and out including but not limited to facility dining areas, kitchen area and common areas. LPA observed that the facility was clean and free of any obstruction of pathways. LPA observed that the facility has all proper and required signs for COVID-19 prevention and safety protocol. LPA observed most sinks had hand washing signs posted. Hand washing areas are supplied with soap and paper towels. LPA observed all staff members wearing surgical masks. LPA observed hand sanitizers throughout the facility. LPA discussed an off-site kitchen waiver with ED. ED expects he will have the facility staffed with a cook within a week. LPA will consult with LPM Rayna Bryson. ED expects the activities staff will return within the next two weeks. LPA granted an extension on the POC from the Administrator qualification citation issued on 7/31/21. The extension has been granted until 12PM on 8/2/21. ED sent LPA the schedule for 8/1/21, LPA confirmed individuals scheduled were present at the facility. ED will send the schedule for the week by 6:30 AM on 8/2/21. No citations issued.the state’s words, verbatim · CDSS document, Aug 1, 2021

Type of visit: Case Management - Health Checks

7/31/21 at 11:00 AM Licensing Program Analyst (LPA) Jaclyn Avila arrived at the facility unannounced to conduct a case management regarding staffing. LPA met with Executive Director Eric Perry, Administrator Darren Trisal and explained the purpose of the visit. Prior to initiating the visit, 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; contacted administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. LPA completed facility screening Currently, there are 2 staff scheduled for day shift, 2 scheduled for PM shift and 1 scheduled for night shift. Per ED, this is normal staffing, the difference is that he is filling shifts and there is no cook. Food is being transported from Roseleaf Gardens to Roseleaf Senior Care. Currently there is not a designated activities person and scheduled activities are taking place twice a week. Activities are not posted. ED has reached out to local registries to assist with staffing to no unveil. LPA confirmed ADLS of residents are being met. At 1:07 PM, LPA walked into the common area of the facility where residents were sitting after their lunch. LPA noted that the kitchen door was left open and did not observe staff in the kitchen or in the common area with 8 residents. Accessible to residents in care were 7 knives. 1 knife was left on the counter top just to the left as you enter into the kitchen. The remainder of the knives were on a magnetic board above the gas stove. At 1:27 PM, LPA observed that staff had not returned to the area and the knives were still accessible. LPA knocked on the administrator's office door which was closed and retrieved Administrator Darren Trisel to advise him. Darren immediately locked up the kitchen making the knives inaccessible. The facility will provide the LIC 500 (personnel roster) to Community Care Licensing (CCL) by 6:30 PM today (7/31/21). The facility will immediately e-mail CCL with any changes to the staff schedule. If there is a call out, the facility will e-mail CCL and notify CCL as to what their plan is to fill the shift. These updates will take place until further notice. On 7/30/21, CCL held a meeting with Peer Services INC regarding staffing. CCL cannot grant a waiver or exception to the following regulation: 87224 Eviction Procedures- (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5)Change of use of the facility. (A) The licensee may, upon no less than sixty (60) days written notice, evict a resident due to change of use of the facility. 1. In addition to written notice to quit requirements specified in Section 87224(d), written notice to evict due to change of use of the facility shall be made to the resident or the resident’s responsible person and shall include all requirements specified in Section 1569.682(a)(2)(A) through (F) of the Health and Safety Code. Administrator Darren Trisal is requesting it be documented that he will be appealing administrator qualifications. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 31, 2021

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(1) · Plan of correction due date: Jul 31, 2021

87705(f)(1)-Care of Residents with Dementia-The following shall be stored inaccessible to residents with dementia:(1) Knives, matches, ...and other items that could constitute a danger to the resident(s). This requirement was not met as evidenced by: Interview and observation. Administrator and facility staff failed keep knives inaccessible to 8 of 8 residents in care. This poses an immediate risk to residents in carethe state’s words, verbatim · CDSS document, Jul 31, 2021

Plan of correction: During the facility visit, administrator removed the prop from the door preventing it from being left open. Violation was corrected at time of visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(a) · Plan of correction due date: Aug 1, 2021

87405(a)-Adminsitrator Qualifications-All facilities shall have a qualified and currently certified administrator. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility. This requirement was not met as evidenced by: Interview and observation: Administrator has failed to be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility. This poses an immediate risk to residents in carethe state’s words, verbatim · CDSS document, Jul 31, 2021

Plan of correction: Licensee agrees to send in the change of administrator paperwork to CCL by 5PM on 8/1/21