Roseleaf Gardens

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

Licensing Program Analysts (LPAs), Kayla Adkison and Marisa Chiarelli, arrived on August 12, 2026 for an unannounced inspection to follow up on substantiated allegations of neglect/lack of care, resulting from an incident report. On October 29, 2024, the Department concluded a complaint investigation which alleged the following: Staff neglect resulted in a resident to be hospitalized, and staff did not ensure a resident consumed an appropriate amount of liquid. The Licensee was cited for California Code of Regulations (CCR), Title 22, § 87411(a) Personnel Requirements- General and CCR, Title 22, § 87705(c)(3)(A) Care of Persons with Dementia. At the time of the case management visit on October 29, 2024, an immediate civil penalty of $500 was issued. Due to the fact that this was a repeated violation, an additional $500 was levied. The licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” Facility staff did not appropriately monitor a resident (R1) in care and provide the necessary care and supervision to meet R1’s health and behavioral needs, resulting in hospitalization and burns/wounds on 15%-18% of R1’s body. Continued on the attached LIC 809-C. Today, August 12, 2026, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on October 29, 2024, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. Assistant Administrator name and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Aug 12, 2026

Type of visit: POC

On May 21, 2026, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced to conduct a Plan of Correction (POC) visit. LPA was greeted by Amanda Harb, Resident Care Coordinator (RCC) , and explained the purpose of the visit. During the visit, it was reported there were 26 residents in the facility and five (5) care staff on shift. On April 8, 2026, LPA conducted an Annual Inspection at the facility and cited the facility for the following Title 22 regulation deficiencies: 87307(d)(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction; and 87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Administrator Grace Hawkins was informed, via email, that LPA would return at a later date to ensure the deficiencies had been corrected. During today's inspections, LPA and RCC toured the facility and made observations. LPA observed one (1) previously blocked exit to be free of obstructions and all facility bathrooms to be clean. LPA directed Administrator, Mariah Mitzel, to cover one (1) shower/bathtub combo in the 600 hall with a shower curtain as the shower needs to be replaced or resurfaced due to aging. LPA observed the door alarm in the 700 hall to be sounding appropriately when opened. The previously mentioned deficiencies have been corrected and will be cleared by LPA. No deficiencies are being cited as a result of this inspection. Exit interview conducted. A copy of this report was provided to Assistant Administrator, Mariah MItzel, via email.the state’s words, verbatim · CDSS document, May 21, 2026

Type of visit: Required - 1 Year

On April 8, 2026, Licensing Program Analyst (LPA) Kayla Adkison and Licensing Program Manager (LPM) arrived at the facility unannounced to conduct a Required Annual Inspection. LPA met with Administrative Assistant (AA) Lillyana Vaughn, and explained the purpose of the visit. LPA spoke with Administrator Grace Hawkins via telephone and confirmed AA would proceed with completing the inspection During the inspection, there were 26 residents and 5 (five) staff providing direct care. LPA observed residents having lunch, watching television, listening to musical performer, and participating in a physical activity with the Activities Coordinator. LPA, LPM and AA toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to: common areas, five (5) resident bedrooms and bathrooms, courtyard, kitchen, and storage areas. LPA observed two common bathrooms in need of cleaning. LPA observed the alarm for one exterior door to be turned off or inoperable. LPA noted in two (2) bedrooms, resident's beds were placed in a position where residents were unable to reach their emergency pull cords in the event the cord was dropped or not placed directly nest to the resident. LPA observed one exterior exit door to be blocked by the presence of a hoyer lift and resident wheelchair. LPA observed each bedroom to have the required furnishings and working lights. LPA observed the facility to be at a comfortable temperature. LPA observed a calendar of activities posted for residents to view. The facility has a 2-day perishable and a 7-day non-perishable amount of food. All residents requiring a special diet are posted for kitchen staff to review. LPA observed all medications, sharps, and cleaning supplies to be locked away and inaccessible to clients in care. Continued on LIC 809 - C LPA observed (3) three fire extinguishers which were last inspected in January 2026. Smoke detectors and carbon monoxide detectors were observed and found to be in working condition. AA was unable to provide proof of the facility conducting emergency drills. LPA reviewed a total of six (6) resident files and five (5) staff files. One (1) staff file and one (1) residnet file were missing record of a negative tuberculosis test. All staff are fingerprint cleared and associated to the facility. All first aid and CPR training was current. Administrator's certificate is current. LPA requested a copy of the most recent LIC 500, current liability insurance, and the facility's emergency disaster plan be forwarded to LPA by end of business on April 10, 2026 Deficiencies are being cited in compliance with Title 22 of California Code of Regulations (see attached LIC 809-D). Exit interview conducted. A copy of this report, and Appeal Rights, were provided to Administrator, via email.the state’s words, verbatim · CDSS document, Apr 8, 2026

The state marks this report as 9 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.

Allegation investigated: Facility does not have sufficient staff to provide care and supervision to residents Staff are not provided with proper training to care for residents. Facility is not reporting incidents to Licensing.

On March 23, 2026, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced for the purpose of delivering complaint findings. LPA Adkison was greeted by Amanda Harb, Resident Care Coordinator (RCC), and explained the purpose of the visit. During the vist, there were 28 residents and 4 staff providing care. During the course of the investigation, LPA reviewed pertinent documents, conducted interviews, and made observations of the facility. Continued on LIC 9099-C Substantiated Allegation: Facility does not have sufficient staff to provide care and supervision to residents It was alleged the facility is operating without enough staff to properly care for residents in care. Five (5) of five (5) staff members interviewed agreed that the facility was understaffed and staff were unable to care for residents properly because of this. Two (2) of two (2) residents interviewed agreed that the facility had been regularly understaffed to meet their needs. One resident, R1, claimed they had waited for approximately two hours for staff assistance to use the restroom. Another resident, R2, claimed they were left unattended in the restroom for approximately 1.5 hours and had been yelling for assistance during this period. Based on observations, interviews, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099-D. Allegation: Staff are not provided with proper training to care for residents. It was alleged that staff at the facility are not being provided with required training. LPA reviewed three (3) employee files at random and found two (2) of three (3) staff reviewed had no current CPR training and one (1) of three (3) had no current First Aid training. Based on observations and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099-D. Continued on additional LIC 9099-C Allegation: Facility is not reporting incidents to Licensing. It was alleged that the facility was not reporting serious or unusual incidents to Community Care Licensing (CCL). During a visit to the facility on October 21, 2025, LPA conducted an interview with Administrator, Bailey Malagon. It is noted that administrator had been employed by the facility for approximately three (3) weeks at the time of the visit. Administrator conducted a review of the facilities in-house incident reporting system between August 2025 and October 2025 and discovered several incidents that had not been reported to CCL including a resident death and (5) separate incidents that required the residents be transported via Emergency Medical Services. Based on observations, interviews, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099-D. Exit Interview conducted. A copy of this report and Appeal Rights were provided to Administrator, Grace Hawkins. Staff does not clean biohazard. It was alleged that staff were not cleaning up soiled briefs from the floor of the facility. During an inspection of the facility, LPA did not observe any soiled briefs or other biohazard materials left on the floor around the facility. Four (4) of five (5) staff members interviewed stated this was not something they had ever observed while working at the facility. Staff stated briefs are disposed of immediately once residents were changed. Although the allegation may have happened, the preponderance of evidence has not been met, and the allegation is therefore UNSUBSTANTIATED Staff not providing residents with new chucks. It was alleged that staff were not changing out resident’s “chuck pads” once they were stained. The facility utilizes washable “chuck pads” and staff are reportedly directed to discard of “chuck pads” that are heavily stained and unsanitary. Four (4) of five (5) staff members interviewed agreed that heavily stained chuck pads are disposed of and replaced with new pads. These staff all claimed that the facility has a large quantity of extra “chucks” for resident use. Although the allegation may have happened, the preponderance of evidence has not been met, and the allegation is therefore UNSUBSTANTIATED Staff left resident in soiled briefs for a period of time. It was alleged that staff left a resident, R3, in soiled briefs for an extended period of time. It was not clear the amount of time this resident was left in soiled briefs, nor was it clear if any rashes or injuries were sustained from this alleged action. Four (4) of five (5) staff interviewed denied leaving this resident in soiled briefs for any extended period of time. These staff indicated all residents are checked every two hours or less, if needed. LPA reviewed staff care notes for this resident and found no indication of the resident sustaining any type of injury that would result from this lack of care. Although the allegation may have happened, the preponderance of evidence has not been met, and the allegation is therefore UNSUBSTANTIATED Continued on additional LIC 9099-C Staff did not provide assistance to resident in a timely manner. It was alleged that a resident (R1) had pushed their call button and waited approximately two hours for assistance from staff. LPA interviewed R1 who stated the same information. R1 stated the facility’s call buttons were inoperable and staff were unable to hear R1 calling for assistance (see substantiated complaint control #59-AS-20251016114017) R1 indicated they had needed assistance using the restroom and was left in their bed for “2-3 hours” after attempting to use the facility call system. R1 further stated “I was soaked and my bed was soaked. This is happening regularly.” R1 was unable to give an approximate day this had occurred. Five (5) of five (5) staff interviewed denied leaving R1 unattended for more than 2 hours at a time as facility protocol is to conduct checks on residents at least every two hours. LPA reviewed facility care notes which stated “This morning when care staff went in to check on resident they found that (R1) was soaked head to toe in urine due to resident completely refusing to have care done during the night because (R1) says (R1) does not want to be woken up i told (R1) that it is the law that care staff change (R1) and check (R1) every 2 hrs (R1) said well if i hit them its not (R1) problem notified rcc of (R1) behavior and faxed (R1) MD. No other concerns at this time.” LPA noted two other instances in the care note records where R1 refused changes by care staff. Although the allegation may have happened, the preponderance of evidence has not been met, and the allegation is therefore UNSUBSTANTIATED Multiple residents experiencing falls at facility while in care of staff It was alleged that several residents were experiencing falls while in the care of staff. LPA reviewed care notes and incident reports that were documented between July 1, 2025 and October 14, 2025, which indicated there were four (4) residents who had sustained five (5) falls total in this period, with one resident falling twice. According to the care notes, all the falls documented were unwitnessed and care staff called Emergency Medical Services immediately upon discovering the residents had fallen and assessing for injury. Although record review does indicate residents had experienced falls, the amount recorded during the 3-month period does not indicate an excessive or “abnormal” number of falls and all the falls were reported as unwitnessed, not while in the direct care of a staff member. LPA interviewed administrator who stated the care plans of each resident who had experienced a fall were updated as needed. Although the allegation may have happened, the preponderance of evidence has not been met, and the allegation is therefore UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Administrator, Grace Hawkins, via email.the state’s words, verbatim · CDSS document, Mar 23, 2026 · control 59-AS-20251016114017

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Mar 30, 2026

87411 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….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 is evidenced by: Based on observation and interview, the licensee did not ensure that facility staff was sufficient in numbers in that (2) two of (2) residents interviewed stated they had been left unattended after requesting assistance from staff. Additionally, (5) of five (5) staff agreed that the facility did not have enough staff on each shift to properly care for residents, which poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 23, 2026

Plan of correction: Administrator agrees to submit a LIC 9098 ensuring their understanding of the regulation. Administrator shall submit the form to LPA by end of business on March 30th, 2026. Previous Administrator has provided proof of in-service training conducted on February 19, 2026, addressing this deficiency.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(1) · Plan of correction due date: Mar 30, 2026

87411 Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This is evidenced by: Based on observation and record review, the licensee did not comply with the regulation stated in that one (1) of three (3) staff files reviewed did not have current First Aid training, which poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 23, 2026

Plan of correction: Administrator agrees to fill out a LIC 9098 ensuring their understanding of the regulation. Administrator shall submit the form to LPA by end of business on March 30th, 2026. Administrator provided proof of staff’s current First Aid training on November 5, 2026. Additionally, Administrator conducted an in-house CPR training for all staff on November 6, 2025 provided by Kiser CPR.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Mar 30, 2026

87211 Reporting Requirements (a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any….(A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. This is evidenced by: Based on observation and record review, the licensee did not comply with the regulation stated in that one (1) resident passed away and the facility failed to inform CCL within seven (7) days, which poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 23, 2026

Plan of correction: Administrator agrees to fill out a LIC 9098 ensuring their understanding of the regulation. Administrator shall submit the form to LPA by end of business on March 30th, 2026. Administrator has provided LPA with an LIC 624A documenting this resident’s death and has been sending incident reports sufficiently to CCL since being notified of the deficiency in October 2025.

Allegation investigated: Resident sustained wound injuries due to staff's neglect

On March 23, 2026, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced for the purpose of delivering complaint findings. LPA Adkison was greeted by Amanda Harb, Resident Care Cooridnator (RCC), and explained the purpose of the visit. During the visit, there were 28 residents and 4 staff providing care. Department of Social Services-Community Care Licensing Division-Investigations Branch, Investigator Blatnick obtained and reviewed records, interviewed staff members and witnesses. In addition, Investigator Blatnick reviewed medical records and facility records. Allegation: Resident sustained wound injuries due to staff's neglect It was alleged that R1 sustained bilateral foot wounds caused by a fungal infection due to staff's neglect. Investigator Blatnick reviewed faciity records and hospital records as well and conducted interviews with facility and Home Health staff. R1 was unable to provide a statement related to the allegation. Based on statements obtained and the records reviewed, Investigator determined it was unclear if staff neglect resulted in the wounds. Although the allegation may have happened, the preponderance of evidence has not been met, and the allegation is therefore UNSUBSTANTIATED. Exit interveiw conducted and a copy of this report was provided to Administrator, Grace Hawkins, via email. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 23, 2026 · control 59-AS-20250723170249

Allegation investigated: Facility phone number has been disconnected causing communication issues.

On March 23, 2026, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced for the purpose of opening a complaint investigation receieved on March 13, 2026. LPA Adkison was greeted by Grace Hawkins, Adminsitrator, and explained the purpose of the visit. During the vist, there were 28 residents and 4 staff providing direct care. Allegation: Facility phone number has been disconnected causing communication issues. It was alleged that the phone number listed for the facility's website had been disconnected, causing family members and the general public to be unable to communicate with residents living at the facility. LPA reviewed the facility's website, which listed the phone number 530-924-5531. LPA called this number and received the message " Sorry, this number is no longer in service." This same phone number was listed for the facility on Google.com. LPA reviewed Yelp.com, which listed the phone number 530-895-0800. LPA called this number and received the message "The number you have called is temporarily unavailable." It is noted that 530-895-0800 is the same phone number Community Care Licensing (CCL) has on record for the facility. Continued on LIC 9099-C Substantiated LPA interviewed staff (S1) who stated they were aware the phone number on the facilities website was incorrect, however, the facility did have a working phone number that S1 had provided to families at an earlier date. LPA interviewed Administrator who stated they were aware of the phone numbers on line being incorrect. The facility is in the process of changing ownership. Administrator stated there is already work being done to update all phone numbers and websites. Administrator further stated the facility has had Comcast out recently to work on the existing phone line, however, they had not completed the job at this time. Based on observation and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Exit Interview conducted. A copy of this report and Appeal Rights were provided to Administrator, Grace Hawkins, via email.the state’s words, verbatim · CDSS document, Mar 23, 2026 · control 59-AS-20260313134725

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(14) · Plan of correction due date: Apr 20, 2026

87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(14) To have reasonable access to telephones, to both make and receive confidential calls. This is evidenced by: Based on observation and record review, the licensee failed to ensure that the facility had reliable and correctly functioning telephone service which prevented families from being able to contact residents. This poses a potential health, safety, and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Mar 23, 2026

Plan of correction: The licensee agrees to arrange to have a functioning telephone number that can be answered at all times. The licensee shall update their website and Google profile to reflect a current, working, telephone number. Licensee shall infom family/POA of each resident of the new phone number, if deemed necessary. POC shall be completed and licensee/administrator shall inform LPA of changes made by end of business April 20, 2026.

Allegation investigated: Facility failed to meet a residents needs in a timely manner.

On January 27, 2026, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced for the purpose of delivering complaint findings. LPA was greeted by Administrator, Bailey Malagon, and explained the purpose of the visit. During the visit, there were 4 staff providing care and 25 residents. During the course of the investigation, LPA reviewed pertinent documents, conducted interviews, and made observations of the facility. Continued on LIC 9099-C Substantiated Allegation Facility failed to meet a residents needs in a timely manner. It was alleged that on October 8, 2025, staff were assisting a Resident (R1) with transferring to the restroom. After assisting R1 with sitting down, staff allowed R1 privacy and informed R1 "they would return in a few minutes." It was alleged that no staff returned to assist R1 for approximately 1.5 hours. R1 reported they verbally called for assistance, however, no staff returned. R1 attempted to get up themselves resulting in a fall where they hit their head. R1 reported they were on the floor for approximately 15 more minutes before staff arrived to help. R1 reported they did not use the bathroom's pull cord for assistance as "we were told they didn't work. " (See complaint investigation #59-AS-20251021112112). R1 indicated they knew the length of time they were left unattended because they were wearing a watch. R1 stated they were left in the bathroom at approximately 7:30 pm and by 9:00 pm nobody had returned. LPA reviewed R1's care notes for March 8, 2025. Care staff noted at 9:50 PM, "Resident attempted to get off the toilet without assistance and landed on butt on the floor. No injury and staff assisted him up. No further concern. MD notified." R1 indicated staff asked if R1 was alright after the fall and then assisted R1 to their bed. Emergency Medical Services (EMS) were not contacted to evaluate R1 for injuries. On March 9, 2025, care notes indicated R1's family member had informed staff of a red bump on R1's head. R1 stated it was from where they had hit their head the night before. LPA reviewed R1's LIC 602 (Medical Assessment) dated August 21, 2025, which indicated R1 had no cognitive conditions and was unable to care for their own toileting needs. LPA reviewed R1's care plan dated July 1, 2025, which indicated "Staff to provide hands-on assistance for bladder or bowel incontinence management." LPA attempted to interview staff members who were present at the time of the incident, but received no return phone calls. Additionally, staff who recorded the care notes documenting the incident are no longer employed at the facility. Based on observations, interviews, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099-D. Exit interview conducted. A copy of this report and Appeal Rights were provided to Administrator, Bailey Malagon.the state’s words, verbatim · CDSS document, Jan 27, 2026 · control 59-AS-20251015114407

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Feb 2, 2026

87411 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 violation is evidenced by: Based on interview and record review, the licensee failed to meet the residents needs in that they did not follow the resident's care plan to provide hands on toileting asisitance and they left the resident unattended for approximately 1.5 hours, resulting in R1 sustaining a fall and injury, which poses a potential health, safety, or personal rights risk to resident's in care.the state’s words, verbatim · CDSS document, Jan 27, 2026

Plan of correction: Administrator agrees to fill out a LIC 9098 ensuring their understanding of the regulation. Administrator shall submit the form to LPA by end of busness on February 2, 2026. Administrator agrees to conduct/provide training pertinent to the regulation. Administrator shall submit an agenda of this training and a signed staff attendance to LPA by end of busness on February 20, 2026.

Allegation investigated: Staff did not ensure resident was properly positioned in shower chair, resulting in a fall Staff did not seek medical attention for resident Staff did not report incident involving resident

On January 27, 2026, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced for the purpose of delivering complaint findings. LPA was greeted by Administrator, Bailey Malagon, and explained the purpose of the visit. During the visit, there were 4 staff providing care and 25 residents. During the course of the investigation, LPA reviewed pertinent documents, conducted interviews, and made observations of the facility. Continued on LIC 9099-C Substantiated Staff did not wear gloves when changing residents’ diapers It was alleged that the facility had run out of gloves and staff were being directed to simply wash their hands between assisting residents with brief changes. LPA interviewed six (6) current and former staff members and no staff had any knowledge of a time when the facility was out of gloves, nor had they ever been directed to not use gloves when changing residents briefs. Two (2) staff mentioned that gloves were being kept in the med room at the facility and new staff may have not know the location of supplies LPA observed a supply order list for the previous three months that showed boxes of gloves being ordered in all sizes for the facility. During an inspection of the facility on July 25, 2025, LPA observed multiple boxes of gloves in the facility for staff use. Although the allegation may have happened, the preponderance of evidence has not been met, and the allegation is therefore UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Administrator, Bailey Malagon. Allegation: Staff did not ensure resident was properly positioned in shower chair, resulting in a fall. It was alleged that during a PM shift on July 13, 2025, a resident (R1) had sustained a fall during a shower while being assisted by three staff members. The resident was not supposed to receive "regular" showers and was instead provided "bed baths" due to R1's bedridden status. Staff reported that the management on shift "insisted" on giving R1 the shower and did not place the resident in the shower chair properly, resulting in R1 falling to the floor and sustaining a cut to their forearm. Staff were interviewed who confirmed the allegation. LPA reviewed R1's care plan dated July 8, 2025, which stated "Bathing - Two Person Assistance- Bed bath, full assistance needed with bed bath as individual is unable to tolerate showering." LPA observed R1's Care Notes dated July 14, 2025, stating "When assisting care staff with transfer, I (staff) noticed a cut on resident's left arm that is about 1 1/2 long. I asked care staff if she knew what happened to resident she said that she had a fall last night (7/13)." Based on observations, interviews, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099-D. Allegation: Staff did not seek medical attention for resident. It was alleged that following R1's fall while in the shower, that staff failed to seek medical attention for the resident. LPA interviewed staff who confirmed this allegation. LPA reviewed R1's care notes which indicated no medical attention was sought for R1. Staff that originally attempted to report R1's fall indicated in the Care Notes that they cleaned and bandaged the cut on R1's arm and there were no further concerns. A follow-up comment from managerial staff indicated "Resident did not have a fall on 7/13, please ensure we are documenting correctly and accurately." LPA reviewed all Special Incident Reports submitted by the facility and there were none mentioning R1 sustaining a fall or that any medical attention had been sought for the resident on this date. Based on observations, interviews, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099-D. Continued on LIC 9099-C Allegation: Staff did not report incident involving resident It was alleged that staff failed to report the previously mentioned incident to Community Care Licensing (CCL) . LPA conducted a review of Special Incident Reports submitted to CCL at the time the incident occurred and found no evidence of the facility reporting the circumstances as required. On October 21, 2025, LPA interviewed Administrator Bailey Malagon who conducted a search of the facilities records and confirmed there were incident reports prepared by staff reporting the previously mentioned incident. Administrator noted there was a Care Note describing the incident and R1's injury, however, a separate staff member provided a follow-up care note denying the allegations ever occurred. Based on observations, interviews, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099-D. Exit interview conducted. A copy of this report and Appeal Rights were provided to Administrator, Bailey Malagon.the state’s words, verbatim · CDSS document, Jan 27, 2026 · control 59-AS-20250715091831

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Feb 20, 2026

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This is evidenced by: Based on observation, interview, and record review, the licensee failed to provide safe accomodations for the resident in that staff did not follow the resident's care plan to have only bed baths resulting in a fall while in the care of staff, which poses a potential health, safety, or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Jan 27, 2026

Plan of correction: Administrator agrees to conduct/provide training pertinent to the regulation. Administrator shall submit a signed staff attendance to LPA by end of busness on February 20, 2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(g) · Plan of correction due date: Feb 20, 2026

87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health... This is evidenced by: Based on observation, interview, and record review, the licensee failed to seek medical assistance for the resdient after a fall and sustained injury,the state’s words, verbatim · CDSS document, Jan 27, 2026

Plan of correction: Administrator agrees to conduct/provide training pertinent to the regulation. Administrator shall submit a signed staff attendance to LPA by end of busness on February 20, 2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Feb 20, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below (D) Any incident which threatens the welfare, safety or health of any resident. This is evidenced by: Based on Observation, Interview, and Record Review, the licensee/administrator failed to report an incident in which R1's welfare was threatened, which poses a potential health, safety, or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Jan 27, 2026

Plan of correction: Administrator agrees to conduct/provide training pertinent to the regulation. Administrator shall submit an agenda of this training and a signed staff attendance to LPA by end of busness on February 20, 2026.

Allegation investigated: Staff did not seek medical attention in a timely manner. Residents do not have access to personal hygiene items

On January 27, 2026, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced for the purpose of delivering complaint findings. LPA was greeted by Administrator, Bailey Malagon, and explained the purpose of the visit. During the visit, there were 4 staff providing care and 25 residents. During the course of the investigation, LPA reviewed pertinent documents, conducted interviews, and made observations of the facility. Continued on LIC 9099-C Unsubstantiated Allegation: Staff did not seek medical attention in a timely manner. It was alleged that a resident had experienced two falls on the same day and staff members failed to seek medical attention for that individual. The complainant in this matter was unsure of the name of the resident, the number of the resident’s apartment at the facility, or the exact date of when the falls occurred. A physical description of the resident was provided; however, the resident was unable to be positively identified. No staff interviewed were able to determine which resident this allegation may have been referring to. Although the allegation may have happened, the preponderance of evidence has not been met, and the allegation is therefore UNSUBSTANTIATED. Allegation: Residents do not have access to personal hygiene items It was alleged that there was a significant shortage in personal hygiene items at the facility including, but not limited to, toothbrushes, lotion, hairbrushes , briefs, and personal wipes. During a facility inspection on June 18, 2025, LPA and Administrator conducted a tour of the facility. LPA observed a large closet full of excess wipes, briefs, and basic toiletries available for residents. Additionally, LPA observed residents’ personal toiletries that were kept in individual caddies for staff to use while assisting residents. Six (6) of six (6) staff interviewed stated they have never observed any resident to go without briefs, wipes or basic toiletries. Staff stated that most resident's families provide any supplies they may need for the month and it is recorded on a log in the facility lobby. Any resident who's supplies were running low, staff notified the families. LPA observed a supply order list for the previous three months that contained toiletry items, multiple packages of briefs, anad multiple packages of wipes. LPA observed a "supply drop - off list" dated for the previous three months that had dozens of entries from family members dropping off supplies. Although the allegation may have happened, the preponderance of evidence has not been met, and the allegation is therefore UNSUBSTANTIATED. Allegation: Facility not meeting incontinence needs of residents in care It was alleged that staff were not meeting the incontinence needs of residents in care by not supplying residents with depends/briefs when necessary and leaving residents in soiled briefs for an extended period. During the course of the investigation, LPA conducted several tours of the facility and observed a strong smell of urine in specific wings of the facility where it was known that resident's with incontinence issues were living. LPA attempted to interview residents who were on an incontinence plan, however, LPA was unsuccessful due to each resident’s dementia diagnosis. On October 25, 2025 LPA was able to interview one (1) resident who indicated there have been several instances where they felt they were “forgotten” about by staff while residing at the facility. The resident indicated that the facility is regularly short staffed and there may have only been one (1) or two (2) staff members available to assist the entire facility. The resident admitted there had been times when they needed to use the restroom and were unable to get out of their bed on their own because staff never responded to their calls or assistance. LPA interviewed several staff members during the course of the investigation. Four (4) of six (6) staff stated that they had observed residents being left in soiled briefs for an unknown extended period of time, particularly at shift changes. Staff stated that on more than one occasion, they would arrive for their shifts and find residents soaked through briefs, "chuck" pads, and down to their mattress while being asleep. Two (2) staff stated that it was facility policy to check residents hourly and it was unreasonable to believe that a resident could soak through their belongings that quickly, indicating staff were not properly meeting the incontinence needs of the residents. Based on observations, interviews, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099-D. Exit Interview conducted. A copy of this report and Appeal Rights were provided to Administrator, Bailey Malagon.the state’s words, verbatim · CDSS document, Jan 27, 2026 · control 59-AS-20250613155200

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Feb 6, 2026

87625 Managed Incontinence (b) In addition to Section 87611... 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 is evidenced by: Based on observation, record review, and interviews, the licensee did not ensure that incontinence needs of residents were being met in that resdients were found soaked through their bedding at shift changes on more than one occasion and the facility has been observed to smell of urine which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 27, 2026

Plan of correction: Administrator agrees to fill out a LIC 9098 ensuring their understanding of the regulation. Administrator shall submit the form to LPA by end of busness on February 6, 2026.

Type of visit: Office

On January 8, 2026, at 2:00 pm, an office meeting was held, via Microsoft Teams, as a follow-up to a Non-Compliance Conference (NCC) which was conducted on June 30, 2025. In attendance representing Community Care Licensing (CCL) were Lauren Crocker, Licensing Program Manager; Troy Ordonez, Licensing Program Manager; Kayla Adkison, Licensing Program Analyst; and Rebecca Knight; Licensing Analyst. Individuals in attendance representing the facility included; Bailey Malagon, Administrator; Mark Cimino, Consultant; Rajesh Rao, Managing Member; Sridhar Nagunuri, Managing Member; and Ramaprasad Samudrala, Managing Member. The purpose of the meeting was to discuss how the facility has responded to issues identified in the previous NCC dated 6/30/2025 along with new concerns that had been brought to the attention of the Department. Multiple topics were discussed during the meeting, including: • Financial concerns including late annual CCL fees resulting in significant fines, multiple unpaid outside vendors, and unpaid or late utility bills. • Recent maintenance concerns regarding the licensee's additional facility Roseleaf Oroville. • A continuing history of administrator turnover at both Roseleaf Oroville and Roseleaf Gardens (Chico). • Licensee/Administrator reporting requirements, including knowledge of items required to be reported, utility shut off notices or financial concerns, and the time frames for reporting. Continued on the attached LIC 809-C. In addition to addressing the concerns identified in the Non-Compliance Plan developed on June 30, 2025, it was requested the facility submit further information to the department, to include: - information regarding the newly appointed Interim Administrator at Roseleaf Oroville and any hiring updates on a permanent Administrator. - an outline of the roles and responsibilities of each Managing Member as it pertains to each facilities day-to-day operations. - an outline of Administrator duties and what authorities the Administrator is given in regards to day-to-day operations and financial decisions. - expansion on the letter provided to CCL by the administrator/licensees to include identifying the root causes of previously mentioned problem areas and what steps facility administration intends to take to ensure future compliance with Title 22 Regulations. Licensees were further informed of the intent of CCL to submit a referral to the department's audit unit to conduct a review of all four Roseleaf facilities. No deficiencies are being cited as a result of this meeting. Exit interviewed conducted. A copy of this report was provided to Bailey Malagon, Administrator, via email to obtain signature.the state’s words, verbatim · CDSS document, Jan 8, 2026

Allegation investigated: Allegation: Staff did not prevent residents’ room from being unsanitary.

On October 21, 2025, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility for the purpose of delivering complaint findings. LPA was greeted by Bailey Malagon, Administrator, and explained the purpose of the visit. At the time of the visit, there were 23 residents in the facility and 3 staff providing care. During the course of the investigation, LPA made observations, conducted interviews, and review records obtained from the facility. Continued on LIC9099-C Substantiated Allegation: Staff did not prevent residents’ room from being unsanitary. It was alleged that staff did not prevent a resident's room from being unsanitary. On April 18, 2025, LPA received photographs of an unspecified resident’s room with what appeared to be feces on the bed and several surfaces. It was alleged that night staff would leave the mess for the following shift to take care of. The Facility Administrator admitted that a resident had been exhibiting this type of behavior. LPA observed the care notes and doctor’s notes for this resident and observed documentation of the facility reaching out to the primary care physician to report the behavior and to have the resident seen by the doctor for a change in condition. LPA interviewed 4 staff, of which, all noted they knew about the residents’ behaviors; however, all staff stated the mess was cleaned up as soon as it was discovered. One staff member stated the resident’s family had cleaned up the mess before during a visit as they were the first ones to observe the resident after it had occurred. However, on April 18, 2025, April 22, 2025, and May 27, 2025, during visits to the facility, LPA observed the same resident’s room to smell strongly of urine. The resident’s bedding was saturated with urine and thus unsanitary. During each of these visits, the scent of urine was strong enough to be detected from the hallway outside of the room. Based on observations, interviews, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099-D. Exit Interview conducted. A copy of this report and Appeal Rights were provided to Bailey Malagon, Administrator.the state’s words, verbatim · CDSS document, Oct 21, 2025 · control 59-AS-20250410131635

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 4, 2025

87303 Maintenance and Operation - (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: Based on observations and interviews conducted, the licensee did not ensure that R1's room was clean, safe, and sanitary on at least three (3) seperate dates, which poses a potential health, safety or personal rights violation.the state’s words, verbatim · CDSS document, Oct 21, 2025

Plan of correction: Licensee/Administrator shall ensure resident's rooms and belongings are kept sanitary and remain odor free. Licensee/Administrator shall create and submit a plan to licensing to address the consistent unsanitary conditions by end of business October 31, 2025.

Allegation investigated: Facilty signal system is inoperable

On October 21, 2025, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced for the purpose of opening a complaint investigation. LPA was greeted by Bailey Malagon, Administrator, and explained the purpose of the visit. During the visit, there were 23 residents in care and 3 direct care staff. LPA and Administrator toured the facility and made observations. Allegation: Facilty signal system is inoperable It was alleged that the facility's emergency pull cords from resident's rooms were inoperable. Staff informed LPA that the pagers for the call system were all missing or inoperable. During the inspection, LPA observed Administrator pull (1) one emergency alert cord from a resident room. Administrator showed LPA that the alert then shows up on a computer in the facilities charting room. LPA noted there were no sounds observed. (2) two of (2) two residents interviewed stated that when they were in need of assistance it took over an hour for staff to come too their need. Administrator stated that once it was known that the pagers were all missing or inoperable, a staff member was temporarily assigned to sit in the charting room to monitor the computer were alerts are recorded. Administrator noted that (5) five new pagers have been ordered and are scheduled to be delivered to the facility on October 23, 2025. Based on observation and interview, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Exit Interview conducted. A copy of this report and Appeal Rights were provided to Bailey Malagon, Administrator. Substantiatedthe state’s words, verbatim · CDSS document, Oct 21, 2025 · control 59-AS-20251021112112

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(i(1)(B) · Plan of correction due date: Oct 23, 2025

87303 Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more... shall have a signal system which shall:(B)Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. Based on observations and interviews conducted, the licensee did not ensure the facility's emergency signal system was operable, which poses an immediate health, safety or personal rights violation.the state’s words, verbatim · CDSS document, Oct 21, 2025

Plan of correction: The LIcensee/Administrator agrees to have the signall system repaired and operable by end of business on 10/24/25. Licensee/Administrator shall submit video proof to LPA of working pagers by end of business 10/24/25. Until the pagers have been received and programmed, the licensee/administrator agrees to have staff check on residents hourly and staff shall sign off on a physical log of these checks.

Allegation investigated: Staff left residents in a soiled diaper for a long period of time.

On September 30, 2025, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility for the purpose of delivering complaint findings. LPA was greeted by Residental Care Coordinator, Amanda Harb, and explained the purpose of the visit. At the time of the visit, there were 26 residents in the facility and 3 staff providing care. Continued on LIC 9099-C. Unsubstantiated Allegation: Staff left residents in a soiled diaper for a long period of time. It was alleged that staff left a resident in soiled undergarments for an unknown, extended, period. LPA interviewed 4 staff members via telephone who all stated residents are changed as soon as possible. Staff reported there are several residents in the facility who are incontinent and require regular toileting care. Staff also reported there are a few residents who may become confused or combative when staff attempt to assist with toileting needs. Staff explained that because of this behavior, there are times when staff may need to allow a brief period when staff need to call for assistance or request a “change of face” for the resident by having a different staff member assist, however, no resident is left in soiled undergarments very long. On April 18, 2025, LPA attempted to interview three residents at the facility but was unsuccessful. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to RCC, via email. Allegation: Staff did not seek medical attention in a timely manner. It was alleged R1 sustained a fall, and the facility failed to seek medical attention for this resident in a timely matter. On March 20, 2025, the department received an incident report documenting R1’s fall that occurred on March 19, 2025. The report further documented R1’s subsequent transport to the hospital for evaluation. Additionally, on March 28, 2025, the department received a separate incident report documenting another transport for R1 to the hospital for follow-up after R1’s bruising from the fall appeared to worsen. Based on information above, it is concluded that the allegation is Unfounded. A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Allegation: Staff did not report an incident to licensing. It was alleged that R1 had sustained a fall that the facility failed to report to licensing. On March 20, 2025, an incident report was provided to Community Care Licensing via fax documenting a fall sustained by R1. Emergency Medical Services (EMS) was called and R1 was transported to the hospital for evaluation. Based on information above, it is concluded that the allegation is Unfounded. A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted and a copy of this report was provided to Residential Care Coordinator, via email.the state’s words, verbatim · CDSS document, Sep 30, 2025 · control 59-AS-20250410131635

Allegation investigated: Staff did not ensure the air conditioner was working properly

On September 30, 2025, Licensing Program Analyst (LPA) arrived at the facility unannouced for the purpose of delivering complaint findings. LPA was greeted by Residnetial Care Cooridnator, Amanda Harb, and explained the purpose of the visit. At the time of the visit, there were 26 residents and 3 staff providing care. Continued on LIC 9099-C. Unsubstantiated Staff did not ensure the air conditioner was working properly It was alleged that the facilities air conditioning system had been broken "on the left side of the building" towards "the 100 hall" and the building was noticeably warm. It was reported most residents were moved from their rooms to the other side of the building. It was further alleged a notice had been issued stating the air conditioner would be fixed by June 10, 2025, and no work had been completed by 4:00 PM that day. On June 11, 2025, LPA Adkison arrived at the facility and met with Administrators Stacey Baxter and Jessica Owen. Administrators informed LPA the broken air conditioners had been replaced that same day. LPA and Administrators toured the facility and made observations. LPA observed 4 (four) air conditioning control panels that read temperatures of 76 degrees F, 76 degrees F, 79 degrees F (left side of building), and 77 degrees F(left side of building). LPA took photos of each panel. Administrator stated the new air conditioners had only been running a couple of hours. LPA noted there were no residents currently living in the halls where the air conditioners were replaced. Administrator confirmed residents were moved to the other side of the building while the facility was waiting for the repair to happen. LPA reviewed an invoice from Bob's Air Repair dated May 26, 2025, and signed by the Licensee to replace two air conditioning systems. This invoice showed payment was received on June 11, 2025, upon completion of the repair. Additionally, LPA observed cell phone text message screenshots dated June 10, 2025, and June 11, 2025, of conversations between the administrators and licensee discussing the scheduling of the repair to completed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Residential Care Coordinator , Amanda Harb, via email. Staff did not ensure facility van was working properly It was alleged the facility's resident transportation van was not in working order. On June 11, 2025, LPA Adkison observed the facility's van to have a dead battery and was not operable. Administrator stated the vehicle is rarely ever used and resident's are transported by family member's to appointments, errands, etc. Administrator further stated that there is an additional vehicle that can be used for resident transportation located at the sister facility Roseleaf Oroville located in Oroville, CA. LPA reviewed the facility's Admission Agreement. On Page 7, Section G, titled "Transportation", the agreement states " We (Roseleaf Gardens) will make available to residents, or otherwise assure the provision of, scheduled transportation to the nearest appropriate health facilities for medical and dental appointments..." Based on observations, interviews, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Exit Interview conducted. A copy of this report and Appeal Rights were provided to Residential Care Coordinator, Amanda Harb..the state’s words, verbatim · CDSS document, Sep 30, 2025 · control 59-AS-20250611081310

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87312 · Plan of correction due date: Oct 10, 2025

87312 Motor Vehicles Used in Transporting Residents ....Any vehicle used by the facility to transport residents shall be maintained in a safe operating condition. This requirement was not met as evidenced by: Based on observation, interviews, and records reviewed, the licensee did not ensure that the facility transportation vehicle was in working order which poses a potential health, safety or personal rights violation.the state’s words, verbatim · CDSS document, Sep 30, 2025

Plan of correction: Licensee/Administrator agrees to ensure the vehicle is in working order by end of business on October 10, 2025. LIcensee/Administrator shall provide proof of purchase for any parts needed and any addiitonal work done on the vehicle to LPA via email by this date.

Type of visit: Case Management - Deficiencies

On July 30, 2025, Licensing Program Analyst (LPA) Kayla Adkison and Licensing Program Manager (LPM) Lauren Crocker arrived at the facility for the purpose of a case management visit. LPA and LPM met with Administrator, Jessica Owen, and explained the purpose of the visit. During the visit, LPA, LPM, and Administrator toured the facility and made observations. LPA and LPM noted two (2) wings of the facility, 100 and 800, were malodorous. Administrator stated that three (3) residents regularly refused showers causing the smell to emit from their rooms. Administrator stated these three residents were not the only residents in these wings, therefore, the smell was affecting other residents in care. It should be noted that are during several other visits to the facility, LPA and LPM have noted the same areas to be malodorous. During the visit, LPA and LPM discussed the Non-Compliance Conference that was held June 30, 2025, and the Plans of Corrections that were submitted to Community Care Licensing. LPM provided notes and requested further clarification regarding how the facility will be following up on areas that had been discussed. Deficiencies are being cited from Title 22 of California Code of Regulations (see attached LIC 809-D). Exit interview conducted. A copy of this report, and Appeal Rights, were provided to Administrator, Jessica Owen, via email.the state’s words, verbatim · CDSS document, Jul 30, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(4) · Plan of correction due date: Jul 31, 2025

Basic Services - 87464(f)(4) Basic services shall at a minimum include:(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications Based on observation and interview, the licensee did not comply with the section cited above as three residents in the facility are refusing showers, causing specific wings of the facility to be maloderous, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 30, 2025

Plan of correction: Administrator/Licensee agrees to create a policy/plan that will be implemented regarding resident refusal of basic services (ADL's) i.e., bathing, dressing, etc. This will be submitted to licensing by end of business on Jully 31, 2025.

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

On June 30, 2025, at 2:00 PM, a Non-Compliance Conference was held via Microsoft Teams. In attendance were Regional Manager (RM) Alycia Rayner, Licensing Program Manager (LVM) Lauren Crocker, Licensing Program Analyst (LPA) Kayla Adkison, Licensees/ Managing Members Rajesh Rao, Sridhar Nagunuri, and Ramaprasad Samudrala , Roseleaf Oroville Administrator Stacey Baxter, and Roseleaf Gardens Administrator Jessica Owens. The purpose of this meeting was to discuss several compliance issues observed by Community Care Licensing Division (CCLD) staff during recent visits to the facility as well as recent complaints submitted to the department. RM, LPM, and LPA discussed specific concerns including: -The facilities multiple exit doors and the use of coded locking mechanisms on each door. Residents are unable to use these doors without the assistance of staff, resulting in a personal rights violation and a fire safety concerns. -Current adequate staffing levels and appropriate training in relation to the quality of care being provided to residents. - Multiple recent deficiencies that have been cited. Continued on LIC 809-C Asa a result of the meeting, the Licensee and Administrators were directed to develop a compliance plan, of which must be tailored to the specific needs of the facility and must address the following key areas: - Quality of Care and Resident Engagement -Staffing and Training -Building Structure and Oversight -Long-term Safety Plan for Building Exits Refer to LIC 9111 for further details. Licensee was directed to have the compliance plan completed and submitted to LPA Adkison by July 11, 2025. Exit interview conducted. A copy of the report has been issued. Signature on on this report acknowledges receipt of these reports.the state’s words, verbatim · CDSS document, Jun 30, 2025

Type of visit: Case Management - Deficiencies

On May 25, 2025, Licensing Program Analyst (LPA) Kayla Adkison, Licensing Program Manager (LPM) Lauren Crocker, and Sacramento North Regional Manager (RM) Alycia Rayner arrived at the facility unannounced to conduct a follow-upCase Management - Deficiencies Inspection. LPA, LPM, and RM met with Administrator, Teresa Eads, and were granted access to the facility. All parties toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to six (6) resident rooms, common areas, two (2) bathrooms, and exterior yard. Many topics were discussed. California Code of Regulations, (Title 22), is being cited on the attached LIC809D. An exit interview was conducted. A copy of this report and appeal rights were provided to Administrator, Teresa Eads. A follow-up meeting has been scheduled for 6/30/25. Invitations will be sent out at a later date.the state’s words, verbatim · CDSS document, May 27, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: May 28, 2025

Residents in all residential care facilities for the elderly shall have all of the following personal rights...To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This is not evidence by: Based on observation and interview, the licensee did not comply with the section cited above as the exit doors are all locked with codes rendering them inoperable which poses an immediate health, safety or personll rights risk to persons in care.the state’s words, verbatim · CDSS document, May 27, 2025

Plan of correction: By COB tomorrow, 5/29/25 the locks on the exits shall be removed or turned off so that they are operable for residents to exit. As additional safety measures all exits shall be alarmed to alert staff. Send proof of correction to LPA by 5/29/25

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: May 28, 2025

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions... which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This is evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in that 1 of 1 cleaning solutions was left in a bathroom cabinet accessible to residents which poses an immediate health, safety or personll rights risk to persons in care.the state’s words, verbatim · CDSS document, May 27, 2025

Plan of correction: By COB tomorrow, 5/29/25 the cleaning solution shall be removed from the bathroom and rendered inaccessible to residents. Send proof of correction to LPA by 5/29/25. Licensee shall provide additional training to staff regarding storage of cleansers and toxins. Proof of this training provided to all staff shall be submitted to LPA by 06/03/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a)(d) · Plan of correction due date: May 28, 2025

(a) The facility shall be clean, safe, sanitary and in good repair at all times...(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility. This is not evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in that 1 of 1 lamp was missing a lightbulb and lampshade. the missing lightbulb poses an immediate health, safety or personll rights risk to persons in care.the state’s words, verbatim · CDSS document, May 27, 2025

Plan of correction: Ensure that all lights are functioning, If lights burn out or are removed they need to be replaced immediately. Prepare a system for staff checking and replacing lights on a regular basis.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87303(a)(1) · Plan of correction due date: May 28, 2025

The facility shall be clean, safe, sanitary and in good repair at all times...Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. Based on observations the licensee did not comply with the section as there were multiple rooms that smelled bad.the state’s words, verbatim · CDSS document, May 27, 2025

Plan of correction: By 5/28/25 the licensee shall identify the rooms (including but not limited to rooms 720, 610, 420, 410, 310, 110, etc.) that need to be deep cleaned and send a plan on who, how, and when the rooms will be cleaned. The facility shall be odor free by 6/27/25.

Type of visit: Required - 1 Year

April 22, 2025 09:30 AM Licensing Program Analyst (LPA) Kayla Adkison and Licensing Program Manager (LPM) Lauren Crocker arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA and LPM were greeted at the door by Caregiver, Kelly Wolfe, and were allowed access to the facility. Administrator Stacey Baxter arrived approximately one hour later. LPA, LPM, and Caregiver Kelly toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to six (6) resident rooms, common areas, four (4) bathrooms, kitchen, med room and exterior yards. Staff and resident files were reviewed. Medications were also reviewed. LPA observed medications to be locked and inaccessible to residents. The common area was clean, odor-free and in good repair. All bedrooms had required furniture, bedding, and lighting. Two resident rooms were odorous. One bathroom was locked and determined to be out of order. The kitchen was clean and in good repair. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. The facility was observed to be at a comfortable temperature. LPA observed multiple fire extinguishers which were serviced in January of 2025 Hot water temperature measured 116 degrees F. There is a schedule of activities planned for the clients. All required postings are displayed within the facility. Many topics were discussed. California Code of Regulations, (Title 22), is being cited on the attached LIC809D. An exit interview was conducted. A copy of this report and appeal rights were provided to Resident Care Coordinator.the state’s words, verbatim · CDSS document, Apr 22, 2025

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Facility staff mismanaging resident supplies. Facility staff do not provide a safe and environment for residents. Facility is in disrepair.

The contents of this report was provided and signed by the administrator on 03/18/25. On 03/18/25 Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 10/22/24. LPA Gurriere met with Diania Bingham, Administrator and explained the purpose of the visit. Facility staff mismanaging resident supplies. During the interview process, the administrator and seven staff persons were interviewed. Documents were obtained to include resident observations, resident roster, Physician’s Report, Individual Service Plan, Resident’s Quarterly Report and staff names and cell numbers. continued Unsubstantiated During the investigation process, most staff reported that they heard that there was a problem with the resident’s pads and briefs going missing; however, did not know why. It was reported that the issue was cleared up when the resident’s pads and briefs were locked and monitored through the facility’s medication room. Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated. Facility staff do not provide a safe and environment for residents. During the interview process, the administrator and seven staff persons were interviewed. Documents were obtained to include resident observations, resident roster, Physician’s Report, Individual Service Plan, Resident’s Quarterly Report and staff names and cell numbers. During the investigation process, nearly all staff reported that a female resident is aggressive to staff persons and at times to other residents. Staff agreed that the resident cannot always help herself due to her diagnosis. Staff stated that they are available to intervene when necessary. Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated. Facility is in disrepair. During the interview process, the administrator and seven staff persons were interviewed. Documents were obtained to include resident observations, resident roster, Physician’s Report, Individual Service Plan, Resident’s Quarterly Report and staff names and cell numbers. During the investigation process, it was reported that the resident’s (Resident 1) bedroom dresser was in disrepair. Staff were interviewed and nearly all stated that they were not aware of the resident’s dresser being in disrepair. Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated.the state’s words, verbatim · CDSS document, Mar 25, 2025 · control 59-AS-20250123105158

Allegation investigated: Facility staff did not seek timely medical attention for resident. Facility staff did not report change in condition to authorized representative. Facility staff do not meet the needs of residents in care. Facility is malodorous.

Amended: Unsubstantiated page moved see 03/25/25 9099. On 03/18/25 Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 10/22/24. LPA Gurriere met with Diania Bingham, Administrator and explained the purpose of the visit. Facility staff did not seek timely medical attention for resident. During the interview process, the administrator and seven staff persons were interviewed. Documents were obtained to include resident observations, resident roster, Physician’s Report, Individual Service Plan, Resident’s Quarterly Report and staff names and cell numbers. continued Substantiated During the investigation process, and review of the resident’s (Resident 1) observation log, it was reported that on 01/15/25, 01/18/25 and 01/20/25, the resident was complaining of shoulder pain. Staff reported that they advised upper management of the resident’s pain, which was their protocol to have the resident sent out by emergency services. The management did not send the resident out until 01/21/25, which was six days later. Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard have been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Facility staff did not report change in condition to authorized representative. During the interview process, the administrator and seven staff persons were interviewed. Documents were obtained to include resident observations, resident roster, Physician’s Report, Individual Service Plan, Resident’s Quarterly Report and staff names and cell numbers. During the investigation process, it was reported that the resident’s (Resident 1) responsible party was not notified of the initial complaint of the resident’s shoulder pain. It was reported that it was at least six days later before the responsible party was notified. The regulations state that when changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard have been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard have been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. The contents of this page has been removed, see LIC 9099 dated 03/25/25. Facility staff do not meet the needs of residents in care. During the interview process, the administrator and seven staff persons were interviewed. Documents were obtained to include resident observations, resident roster, Physician’s Report, Individual Service Plan, Resident’s Quarterly Report and staff names and cell numbers. During the investigation process, nearly all staff reported that staff are not meeting the needs of residents in care. It was stated that generally there are two care providers and one medication technician for 30 plus residents. It was reported that frequently a staff person will “call out” meaning not come to work, which then leaves one care provider and one medication technician to take care of 30 plus dementia residents. Staff reported that it is impossible to ensure that all residents are showered on their scheduled shower day and that their needs are not being met. Part of the allegation included that the resident’s were not seeing a podiatrist. The administrator provided documentation that a person from a clinic comes to the facility quarterly to provide care for the resident’s podiatry needs. The document indicated that approximately 10 residents received services on 01/20/25. Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard have been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. Facility is malodorous. During the interview process, the administrator and seven staff persons were interviewed. Documents were obtained to include resident observations, resident roster, Physician’s Report, Individual Service Plan, Resident’s Quarterly Report and staff names and cell numbers. During the investigation process, it was reported that residents use the common area toilets and that at times the toilets do get clogged and that there is an odor. Staff stated that sometimes resident’s put in too much paper products and this is part of the reason that the toilets clog up. Staff reported that they are responsible for unclogging the toilets as soon as they can. The administrator reported that if there is a problem that cannot be fixed by the staff, she will call a plumber. It was reported that when the toilets are plugged, it may cause a foul odor.the state’s words, verbatim · CDSS document, Mar 18, 2025 · control 59-AS-20250123105158

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(d) · Plan of correction due date: Mar 19, 2025

87464 Basic Services - A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement was not met as evidenced by: Based on interviews and a review of the resident’s observation log the licensee/administrator did not send the resident out for emergency services. This poses an immediate risk to residents in care.the state’s words, verbatim · CDSS document, Mar 18, 2025

Plan of correction: The administrator agrees to write a plan of correction advising how she will avoid this type of citation in the future.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Mar 19, 2025

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. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by: Based on interviews and a review of the resident’s observation log the licensee/administrator did not notify the resident’s responsible party, as required. This poses a immediate risk to residents in care.the state’s words, verbatim · CDSS document, Mar 18, 2025

Plan of correction: The administrator agrees to write a plan of correction advising how she will avoid this type of citation in the future. Repeat violation, $250. civil penalty.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f) · Plan of correction due date: Mar 25, 2025

Basic Services - Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code Section 1569.2(c). This requirement was not met as evidenced by: Based on interviews and a review of the records, the licensee/administrator did not ensure that residents were receiving their showers as required. This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Mar 18, 2025

Plan of correction: The administrator agrees to submit to the licensing agency the Personnel Report (LIC 500) advising how she will meet the needs of the residents by increasing staffing.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 25, 2025

Maintenance and Operation - 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: Based on interviews, the licensee/administrator did not ensure that the facility was without clogged toilets and an odor throughout the facility. This poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Mar 18, 2025

Plan of correction: The administrator agrees to write a plan of correction advising how she will avoid this type of citation in the future.

The state marks this report as 8 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Allegation investigated: Staff is not providing regular showers or bathing to resident Staff is not providing oral hygiene care to resident. Resident admitted to the hospital with unexplained broken ribs Staff failed to seek medical attention in a timely manor resulting in resident being admitted to the hospital with sepsis

On February 12, 2024 at approximately 01:00 PM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Roseleaf Gardens for the purpose of delivering complaint findings. LPA was greeted at the door by Administrator, Stacey Baxter, and was granted access into the facility. During the course of the investigation, LPA Sarangi interviewed staff members, witnesses and the Long-Term Care Ombudsman (LTCO) assigned to the facility. In addition, LPA reviewed the resident roster and toured the facility. The Departments Investigations Branch Investigator interviewed staff members and witnesses. In addition, the Investigator reviewed medical records and facility records. Complaint alleges that Staff is not providing regular showers or bathing to resident. Based on interviews that were conducted, LPA could not prove or disprove the allegation occurred. Furthermore, LPA received inconsistent statements as it relates to the allegation. LPA could not corroborate the allegation. (Report continued on LIC 9099C) Unsubstantiated Complaint alleges that Staff is not providing oral hygiene care to resident. Based on interviews that were conducted, LPA could not prove or disprove the allegation occurred. LPA conducted an interview with a witness and learned that the facility provided care to the resident as it relates to oral hygiene. Furthermore, LPA conducted an additional interview with the Long Term Care Ombudsman (LTCO) and learned that the facility was giving the best to care for the resident even though the resident had underlying health conditions. LPA could not corroborate the allegation. Complaint alleges that Resident admitted to the hospital with unexplained broken ribs. The Departments Investigations Branch Investigator, Blatnick reviewed hospital records and conducted an interview with a facility staff member. During the interview, the Department learned that the resident fell during a transfer from the bed to the wheelchair. It is noted that the residents’ knees buckled causing the resident to fall on the floor and sustain a laceration to the forehead. Resident was subsequently transferred to the hospital where resident received three sutures and a skin tear on the left elbow. Investigator Blatnick reviewed the medical records which noted no fractures. Facility staff did not know how the resident could have sustained a broken rib. The Department could not corroborate the allegation. Complaint alleges Staff failed to seek medical attention in a timely manor resulting in resident being admitted to the hospital with sepsis. The Departments Investigations Branch Investigator, Blatnick reviewed hospital records and conducted an interview with a facility staff member. During interviews with facility staff, it was revealed that the resident was sent to the hospital immediately after showing signs of a change of condition. Investigator Blatnick reviewed the medical records which did not indicate that the resident had sepsis or severe changes in health. After the resident returned to the facility, staff at the facility noted changes but nothing that warranted a hospital visit. During observation of the resident, staff observed the resident to be less mobile and more depressed. Resident was subsequently hospitalized due to paleness of the skin and a fever. The Department could not corroborate the allegation. A finding that the complaint allegations of Staff is not providing regular showers or bathing to resident, Staff is not providing oral hygiene care to resident, Resident admitted to the hospital with unexplained broken ribs and Staff failed to seek medical attention in a timely manor resulting in resident being admitted to the hospital with sepsis are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator. During interviews with facility staff, the Department learned that the resident was admitted to the Hospital with an unstageable pressure injury on the coccyx and an unstageable pressure injury on the heal of the resident. Staff observed the pressure injury and notified the Administrator and the Residential Care Coordinator. Administrator reported this to the Primary Care Physician who in turn referred the resident to Home Health. The resident’s insurance was denied for home health. The Administrator was unable to indicate what the facility did to address the wound after the home health was denied other than putting medical honey on it and cleaning it daily. The facility did not seek any other medical options when they found out home health was being denied. During an interview with the doctor, the doctor informed Investigator Blatnick of not being aware of the residents’ pressure injuries. In addition, the doctor was never sent a fax by the facility regarding the injury. The facility provided no proof or documentation that they had notified the doctor or home health. Facility staff described the wound as “small and red” but when resident presented to the Hospital it was an unstageable wound (See LIC 9099D). Deficiencies cited from the Health and Safety Code. Appeal rights were provided. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in Civil Penalties. LPA advised the Administrator that the Department may seek an Enhanced Civil Penalty due to the nature of the allegation. Exit interview was conducted, and a copy of this report was signed and given to the Administrator along with Appeal Rights.the state’s words, verbatim · CDSS document, Feb 12, 2025 · control 59-AS-20240708155440

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Feb 13, 2025

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. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by: Based on observation of records and interviews that were conducted by the Department of Social Services-Community Care Licensing Division-Investigations Branch, Investigator Blatnick, the facility did not seek any other medical options or communicate with the doctor regarding the resident’s condition which presents an immediate health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Feb 12, 2025

Plan of correction: Licensee/Administrator shall conduct staff training and provide proof of that training to Community Care Licensing. In addition, Licensee/Administrator shall fill out an LIC 9098-Self-Certification understanding of the regulation. Licensee/Administrator shall also provide a statement on how future compliance will be met. POC due date February 13, 2025

Type of visit: Case Management - Incident

On February 12, 2024 at approximately 01:30 PM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Roseleaf Gardens for the purpose of conducting a Case Management-Incident Inspection. LPA was greeted at the door by Administrator, Stacey Baxter, and was granted access into the facility. On January 27, 2025, an SOC 341 and an Incident report was forwarded to Community Care Licensing Division (CCLD) regarding a resident to resident altercation. Administrator reported that there were no severe injuries and that the facility contacted the Primary Care Physician. The primary aggressive resident was reassessed by the Primary Care Physician and changes were made to the medication. As of February 12, 2025, there has been no incidents of aggression. On February 11, 2025, an incident report was forwarded to Community Care Licensing Division (CCLD) regarding a resident fall. A review of the Incident Report revealed very limited information as to what the outcome of the fall was (See LIC 9102-Technical Advisory). Administrator did report that the resident returned back with no new orders. LPA educated the Administrator on the importance of ensuring that ALL information is accurately transcribed on the LIC 624 as outlined in Title 22 Regulations. No Deficiencies were cited during today's Case Management-Incident inspection. Exit interview was conducted, and a copy of this report was signed and given to the Administrator.the state’s words, verbatim · CDSS document, Feb 12, 2025

Allegation investigated: Staff did not provide adequate care and supervision to a resident

On November 13, 2024 at approximately 08:30 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Roseleaf Gardens for the purpose of delivering complaint findings. LPA was greeted at the door by Resident Services Director, Don Daniels, and was granted access into the facility. During the course of the investigation, LPA reviewed facility records, resident records and interviewed staff. Resident could not be interviewed. Complaint alleges that Staff did not provide adequate care and supervision to a resident. Based on an observation of facility records and an interview that was conducted with the Administrator via email, the preponderance of evidence standard has been met. LPA reviewed the Care Plan and observed the document to reflect that the facility would assist with bathing at a moderate level on Wednesdays and Fridays. (Report continued on LIC 9099C) Substantiated During a review of facility care notes, LPA observed that on Friday, July 12, 2024, and Wednesday, July 17, 2024, the bathing was not documented as being completed with no proof that the resident ever denied those showers. Furthermore, On October 23, 2024, LPA conducted an interview with the Administrator via email and learned that the facility has no corroborating evidence to support that the resident denied the showers during said dates (See LIC 9099D). LPA educated the Administrator on the importance of ensuring that Care and Supervision are being given to all residents in care at the facility as outlined in Title 22 Regulation and Health and Safety Code §1569.2. Deficiencies cited from the Health and Safety Code. Appeal rights were provided. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in Civil Penalties. Exit interview was conducted, and a copy of this report was signed and given to the Resident Services Director along with Appeal Rights. Complaint alleges that Staff did not meet a resident's incontinence needs. Based on interviews that were conducted, LPA received inconsistent statements throughout the course of the investigation. LPA reviewed the LIC 602 which revealed that the resident does not make it to the bathroom on time. During this review, it is noted on the LIC 602 that the resident can care for toileting needs. Furthermore, LPA could not corroborate the above allegation due to insufficient evidence. Complaint alleges that Resident sustained unexplained injuries while in care. Based on interviews that were conducted, LPA received inconsistent statements throughout the course of the investigation. LPA reviewed the Hospital Notes and observed notations that the resident has had two unwitnessed falls at the facility. Furthermore, LPA could not corroborate the above allegation due to insufficient evidence. Complaint alleges that Staff did not address a resident's change in medical condition. Based on interviews that were conducted, LPA received inconsistent statements throughout the course of the investigation. LPA reviewed the Hospital Notes and observed notations that the resident has decreased appetite and that a higher level of care is possibly needed for the resident. During the hospital evaluation, the attending doctor suggested 24-hour supervision/care for the resident and that an assisted living environment might not be suitable for the resident. Furthermore, LPA could not corroborate the above allegation due to insufficient evidence. A finding that the complaint allegations of Staff did not properly report incidents involving a resident, Staff did not meet a resident's incontinence needs, Resident sustained unexplained injuries while in care and Staff did not address a resident's change in medical condition are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Resident Services Director.the state’s words, verbatim · CDSS document, Nov 13, 2024 · control 59-AS-20240822114312

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.2 · Plan of correction due date: Nov 14, 2024

Health and Safety Code §1569.2 (c) “Care and supervision” means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This requirement was not met as evidenced by: Based on an observation of facility records and an interview with the Administrator, the facility Care Notes reflected that the bathing was not documented as being completed with no proof that the resident ever denied the showers. LPA conducted an interview with the Administrator via email and learned that the facility has no corroborating evidence to support that the resident denied the showers during said dates which is an immeidate health, safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Nov 13, 2024

Plan of correction: Licensee/Administrator to submit an LIC 9098 understanding of the Health and Safety Code Regulation. In addition, Licensee and Administrator shall conduct staff training outlining the regulations surrounding Care and Supervision. Licensee/Administrator shall provide a statement on how future compliance will be met. POC due date: November 14, 2024

Allegation investigated: Staff neglect resulted in a resident to be hospitalized. Staff did not ensure a resident consumed an appropriate amount of liquid.

On 10/29/24 Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 07/17/24. LPA Gurriere met with Stacey Baxter and explained the purpose of the visit. Staff neglect resulted in a resident to be hospitalized. During the interview process, attempts were made to talk to the 11 staff persons that may have been present during an incident; however, most of the staff have resigned from their positions, calls were not returned, or staff were working a separate shift. Resident documents were received and reviewed to include the Physician’s Report, Facility Observation Notes, and Incident Reports. In addition, records were collected from Enloe Medical Center, UC Davis Hospital, photos/videos, and a report from the resident’s physician. During the investigation, it was reported that on 06/30/24 it was discovered that a resident (R1) was observed outside on the patio area of the facility laying on the concrete. It was believed that the resident was outside for 30 to 90 minutes in temperatures exceeding 100-degrees. The facility staff contacted emergency services and they arrived to take the resident to the emergency room. Substantiated On 06/30/24 the resident was transported to the hospital. It was reported that R1 was diagnosed with 3rd degree burns on the posterior left leg and posterior right leg, hypotensive dehydrated, hypothermic, and heat stroke/heat exhaustion. It was reported that the resident needed a higher level of care and was sent to a Skilled Nursing Facility (SNF). While at the SNF, it was determined that the resident needed a higher level of care and was sent to a medical center for observation and treatment. On 07/13/24 the resident was transported to the medical center. There is where it was reported that the resident was suffering from burns to her posterior buttocks, thighs, and legs. UC Davis documents state that the resident had approximately 9% Total Body Surface Area (TBSA) to the left posterior leg and right lower posterior leg due to a scald burn of the resident laying on the concrete. On 09/19/24 the R1 was seen by the physician who reported that R1 was being seen for burns to the right leg and a burn to the left leg. In addition, the physician’s notes state that the resident has a “Necrotic tendon/tissue with necrotic tendon unattached distally…” The resident suffered from dead tissue/tendon that couldn’t be saved due to a lack of blood flow, or devascularization. A video was reviewed by LPA Gurriere of the dead tendon. 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 is found to be Substantiated. California Code of Regulations, (Title 22), is 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. At the time of the complaint visit, an immediate civil penalty of $1000 shall be assessed for a violation of California Code of Regulations Personnel Requirements - 87411(a) cited on 07/10/24 and 10/29/24. At this time, the issuance of an additional civil penalty is still being determined and the Administrator has been informed that an additional civil penalty may be assessed, at a later date, based on Health and Safety Code §1569.49. Staff did not ensure a resident consumed an appropriate amount of liquid. During the interview process, attempts were made to talk to the 11 staff persons that may have been present during an incident; however, most of the staff have resigned from their positions, calls were not returned, or staff were working a separate shift. Resident documents were received and reviewed to include the Physician’s Report, Facility Observation Notes, and Incident Reports. In addition, records were collected from Enloe Medical Center, UC Davis Hospital, photos/videos, and a report from the resident’s physician. During the investigation and records reviewed, Enloe Medical Center reported that the resident suffered “3rddegree burns on her posterior left leg and posterior right leg, hypotensive dehydrated, hypothermic and heat stroke/heat exhaustion.” 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 is found to be Substantiated. California Code of Regulations, (Title 22), is 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, Oct 29, 2024 · control 59-AS-20240717115839

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Oct 30, 2024

Personnel Requirements – Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs or the physical arrangements of the facility require such additional staff for the provision of adequate services. The requirement is not met as evidence by: Based on record review, the licensee did not provide adequate care and supervision by leaving a dementia resident unsupervised outside for an extended period which poses an immediate Health, Safety, Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 29, 2024

Plan of correction: The licensee/administrator agrees to submit to the licensing agency a plan for each resident that is a fall risk. Advise the type of prevention, escort services needed, and training materials that will be used to inform the staff. A civil penalty in the amount of $1000.00 will be served this date, as the facility has been cited two times; dates 07/10/24 and 10/29/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(3)(A) · Plan of correction due date: Oct 30, 2024

Care of Persons with Dementia – Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: Dementia care including, but not limited to, knowledge about hydration, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living. Based on record review, the licensee did not provide adequate care and supervision by leaving a dementia resident unsupervised outside for an extended period which poses an immediate Health, Safety, Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 29, 2024

Plan of correction: The licensee/administrator agrees to submit to the licensing agency what plan is in place to ensure that the residents are being hydrated each day.

Allegation investigated: Staff are overmedicating resident in care. Staff did not report incident(s) involving resident as necessary. Facility does not have sufficient staffing to meet the needs of resident(s) in care. Administrator/designee is not present at the facility a sufficient amount of time. Staff do not ensure that resident has a sufficient quantity of food/liquids while in care.

On 08/06/24 Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 05/03/24. LPA Gurriere met with Michelle Long, Administrator Assistant and explained the purpose of the visit. Staff are overmedicating resident in care. During the interview process, the assistant administrator, two hospice nurses and three staff persons were interviewed. The residents were not interviewed due to their dementia status. In addition, the following documents were obtained and reviewed: Physician’s Report, Medication Administration Records (MARs), Daily Care Logs, Admission Agreement, staff work schedules, and staff telephone numbers. continued Unsubstantiated During the investigative process, it was indicated and verified that the resident (Resident 1) could not determine, per the physician’s order that she could indicate when she needed a Pro Re Nata (PRN). The physician ordered that the resident take Lorazepam and Phenobarbital on an “as needed basis” for anxiety. Staff did utilize the PRN order and stated that they did contact the on-call hospice nurse to get permission to give additional dosage; however, documentation could not be provided to support that the staff did call the hospice nurse when giving the PRN. It could not be proven one way or the other if the staff were over medicating the resident in care. Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the above finding is Unsubstantiated. Note: The regulations clearly state to record the date and time of each contact with the physician. In this case the staff were to contact the hospice nurse prior to giving the resident the PRN for Lorazepam and Phenobarbital, provide the date and time of each contact with the physician (hospice) and the physician’s (hospice) directions, were to be documented and maintained in the resident’s facility record. A separate citation will be given on an LIC 809 document indicating that the staff did not document when the hospice nurse was contacted to provide the resident with the PRN. Staff did not report incident(s) involving resident as necessary. During the interview process, the assistant administrator, two hospice nurses and three staff persons were interviewed. The residents were not interviewed due to their dementia status. In addition, the following documents were obtained and reviewed: Physician’s Report, Medication Administration Records (MARs), Daily Care Logs, Admission Agreement, staff work schedules, and staff telephone numbers. During the investigation, it was reported that the resident (Resident 1) may have suffered a fall and that it was not reported to the family members or the licensing agency. It was stated that the resident may have fallen; however, when interviewing staff, they indicated that they were not knowledgeable about a fall and if the resident did fall, it would have been reported to the family and to licensing, as required. Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the above finding is Unsubstantiated. Facility does not have sufficient staffing to meet the needs of resident(s) in care. During the interview process, the assistant administrator, two hospice nurses and three staff persons were interviewed. The residents were not interviewed due to their dementia status. As mentioned, the staff work schedules were reviewed. During the investigation, it was determined that for the most part there is sufficient staffing in that staff reported that there are three care providers and one medication technician that work the floor daily. It was also reported that the assistant administrator is available to provide support. Staff indicated that all Activities of Daily Living (ADLs) were being provided to include toileting, transferring, bathing, dressing, escorting to meals, medication administration, etc. Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the above finding is Unsubstantiated. Administrator/designee is not present at the facility a sufficient amount of time. During the interview process, the assistant administrator, two hospice nurses and three staff persons were interviewed. The residents were not interviewed due to their dementia status. During the investigation process, as mentioned the assistant administrator, hospice nurse and staff were interviewed. It was reported by the assistant administrator that she works weekly and at times on Saturdays. The staff indicated that the assistant administrator is available at the facility during the work week to assist in meeting the needs of the residents. The hospice nurse stated that she generally works with the Resident Care Coordinator and that he is available. Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the above finding is Unsubstantiated. Staff do not ensure that resident has a sufficient quantity of food/liquids while in care. During the interview process, the assistant administrator, two hospice nurses and three staff persons were interviewed. The residents were not interviewed due to their dementia status. In addition, the following documents were obtained and reviewed: Physician’s Report, Medication Administration Records (MARs), Daily Care Logs, Admission Agreement, staff work schedules, and staff telephone numbers. During the investigation, the resident’s (Resident 1) Daily Care Logs were reviewed and there was a clear indication that the resident was eating and drinking throughout the day. Towards the end of her hospice services, the resident was receiving pureed food. All staff indicated that they felt that the resident was eating and drinking except for when she was sleeping or on hospice care and could no longer swallow. Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the above finding is Unsubstantiated.the state’s words, verbatim · CDSS document, Aug 6, 2024 · control 59-AS-20240503152347

Type of visit: Case Management - Deficiencies

On 08/06/24 Donna Gurriere, LPA is conducting a case management visit to follow up on a complaint investigation that was received on 05/03/24. Case Number: 59-AS-20240503152347. Met with Michelle Long, Administrative Assistant. During the investigation of the complaint, it was determined that the facility staff were to record the date and time of each contact with the physician when giving a resident (Resident 1) her Pro Re Nata (PRN). In this case the staff were to contact the hospice nurse prior to giving the resident the PRN for Lorazepam and Phenobarbital, provide the date and time of each contact with the physician (hospice) and the physician’s (hospice) directions, were to be documented and maintained in the resident’s facility record. The staff did not document the contact with the physician (hospice) as required. A separate citation will be given this date indicating that the staff did not document when the hospice nurse was contacted to provide the resident with the PRN. 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 is found to be Substantiated. California Code of Regulations, (Title 22), is 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, Aug 6, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(d)(1)(2) · Plan of correction due date: Aug 7, 2024

If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided all of the following requirements are met: Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication. The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record. This requirement was not met as evidenced by: Based on interviews and records reviewed, the licensee did not ensure that a document indicating the date and time of each contact with the physician (hospice) and the physician’s (hospice) directions were documented and maintained in the resident’s file.the state’s words, verbatim · CDSS document, Aug 6, 2024

Plan of correction: The administrator agrees to have a document in each resident’s file that indicates when the physician/hospice is called to give a PRN. This does not include the standard PRN letter related to over-the-counter meds. The administrator shall develop a document for each resident and shall submit a copy of what the document contains that the facility staff will use. A skilled medical professional shall provide training to the staff in regards to the citation.

Type of visit: Case Management - Incident

On July 10,2024, Licensing Program Analysts (LPAs),Jaynae Boyles and Farhaan Sarangi arrived unannounced at Roseleaf Gardens for the purpose of conducting a Case Management-Incident inspection. During the Case Management-Incident inspection, LPA requested the following document(s): -LIC 602 -Incident Report During the Document Review of the LIC 602 (See Document review-LIC 602), the resident is unable to leave the facility unassisted. However, Resident R1 eloped from facility without staff knowledge on June 30, 2024. Current medical assessment dated for 4/5/23 for resident states resident is not able to leave facility unassisted. Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Civil Penalties were assessed today for the amount of $250.00. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in additional civil penalties. Exit interview was conducted with the Administrator and appeal rights were given to the Administrator.the state’s words, verbatim · CDSS document, Jul 10, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jul 10, 2024

87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs or the physical arrangements of the facility require such additional staff for the provision of adequate services. The requirement is not met as evidence by: Based on record review, the licensee did not provide adequate care and supervision by leaving a dementia resident unsupervised outside for an extended period of time which poses an immediate Health, Safety, Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 10, 2024

Plan of correction: Licensee/Administrator will submit a Plan of Correction on how future compliance will be met. Civil Penalties were assessed today for the amount of $250.00 Plan of Correction due on July 11, 2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(c)(5) · Plan of correction due date: Jul 10, 2024

Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. The requirement is not met as evidence by: Based on record review, the licensee did not provide provide an updated medical assessment for a dementia resident which poses a potential Health, Safety, Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 10, 2024

Plan of correction: The facility will develop and implement a strategy to track and monitor annual medical assessments for residents with Dementia, The Facility will inform the LPA of this process, and ensure that all annual medical assessments for residents for Dementia. Plans of Correction due by July 17, 2024

Type of visit: Case Management - Incident

On July 2, 2024, LPA Boyles and LPA Sarangi arrived at the facility unannounced to discuss and incident that occurred on June 30 2024. However, due to the evacuations occurring at the sister facility in Oroville CA there was no administrator to meet and discuss the incident report. LPA will arrive at a later date to discuss the incident.the state’s words, verbatim · CDSS document, Jul 2, 2024

Allegation investigated: Staff are not assisting to change resident's clothes regularly.

/25/2024 Licensing Program Analyst Jaynae Boyles made an unannounced visit to the facility and met with Resident care corrdinator. The purpose of this visit was to deliver the results of a complaint investigation. Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Appeal rights were provided. An exit interview was conducted. A copy of the report was provided to the facility. Continued to 9099C Substantiated LPA reviewed the following documents: Admissions agreement, preappraisal, care plan, medical assessment (602) and recorded care report for R1. The LPA interviewed R1. LPA investigated the allegation, “Staff are not assisting to change resident's clothes regularly”. Documents reviewed indicated that R1 was assessed at the onset of placement for the need for assistance with dressing. R1’s medical assessment indicates that the resident needs assistance with dressing. R1’s care plan indicated that the facility would be providing the resident with assistance with daily dressing two times a day because the resident has use of only the left side due to a stroke. Client interview revealed that the resident was not assisted in changing their clothing for four days, and this has occurred on more than one occasion. R1 could not remember the specific dates in which the previous incidents occurred. R1 indicated that when a specific staff is not present at work R1 is not assisted with changing their clothing. LPA reviewed the residents Recorded Care report for the last two months at the facility. A review of this record indicates that this tool is not being utilized at the facility to document that the facility staff have completed the tasks with residents. The documentation within this document is inconsistent and sporadic with documentation of the completed tasks.the state’s words, verbatim · CDSS document, Apr 25, 2024 · control 59-AS-20240318152248

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.2(c) · Plan of correction due date: Apr 25, 2024

Care and supervision” means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This requirement was not met as evidenced by: The resident was not assisted with dressing as an expressed need outlined in residents medical assessment, preapprasial and care plan from 3/11-3/15/2024, four days without assistance with dressing.the state’s words, verbatim · CDSS document, Apr 25, 2024

Plan of correction: Facility agrees to create a plan to ensure that, residents are receiving the care outlined within their needs and services plan. Facility will ensure that staff are documenting the completion of the needs and services outlined in resident care plans. Facility will also conduct a training with staff regarding the importance of resident observation and documentation of ADLs and submit to LPA by the POC due date of 05/02/24.

Allegation investigated: Staff did not provide medication as prescribed. Staff altered a resident's medication without consent. Staff did not provide adequate supervision resulting in excessive falls.

On 03/19/24 Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 01/30/24. LPA Gurriere met with Don Daniels and explained the purpose of the visit. Staff did not provide medication as prescribed. During the interview process, numerous documents were obtained. Documents included Physician’s Reports, Medication Administrative Records (MARs), Admission Agreements, Incident Reports, and prescription orders. During the investigation, the administrator and several staff persons were interviewed. The residents were not interviewed due to their dementia status. A facility visit was conducted and the two residents (Resident 1 and Resident 2) in question had their medications reviewed by the LPA. Resident 1 had an order in place to allow for her medications to be crushed. During the time of the visit, Resident 2 did not have an order in place to alter the resident’s medications. Medication for Resident 2 was not given as prescribed. Substantiated Staff altered resident medication without consent. As stated in the aforementioned, Resident 1 and Resident 2 in question had their medications reviewed by the LPA. Resident 1 had an order in place to allow for her medications to be crushed. During the time of the visit, Resident 2 did not have an order in place to alter the resident’s medications. Medication for Resident 2 was altered without approval. Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D. One citation is issued for both allegations, as the allegations overlap with one another. Staff did not provide adequate supervision resulting in excessive falls. During the interview process, documents were obtained. Documents included Incident Reports for the month of December 2023. During the investigation, the administrator and several staff persons were interviewed. The residents were not interviewed due to their dementia status. The incident reports indicated that there were several falls by the residents. The administrator and several staff were asked if a process is in place when residents are at fall risk. It was reported that a procedure or a fall risk plan is not in place for individual residents. In addition, staff reported that they have not been trained on a specific “fall risk plan” for the individual residents that have ongoing falls. 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 is found to be Substantiated. California Code of Regulations, (Title 22), is 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, Mar 19, 2024 · control 59-AS-20240130112602

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(6) · Plan of correction due date: Mar 20, 2024

Incidental Medical - 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: When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement was not met as evidenced by interviews and documentation review. The licensee failed to ensure that a prescription order was in place to crush a resident’s medication. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 19, 2024

Plan of correction: Administrator agrees to ensure that a physician’s order is in place to alter or crush a resident’s medication. The administrator will submit a copy of her understanding to the licensing agency

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Mar 20, 2024

Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) 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 interviews and documentation review. The licensee failed to comply with the Health and Safety code cited above. A fall risk care plan was not in place. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 19, 2024

Plan of correction: The administrator agrees to assess all residents that are a fall risk and prepare a plan. Training shall be provided to care providers regarding prevention practices of residents that are a fall risk. The administrator agrees to submit to the licensing agency the materials used to train the care providers and a sign in sheet of those that were trained.

Type of visit: Required - 1 Year

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. 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.the state’s words, verbatim · CDSS document, Mar 5, 2024

The state marks this report as 8 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Allegation investigated: Staff are not meeting resident's needs

/29/2024 Licensing Program Analyst (LPA) Jaynae Boyles made an unannounced visit to the facility and met with Resident Care Corrdinator, Don Daniels. The purpose of this visit is to deliver the results of a complaint investigation. During the interview process, the Administrator, five staff members and witnesses were interviewed. During the review of records, LPA reviewed the files of one resident, including incident reports, medical records, admissions agreement. LPA investigated the allegation, “Staff are not meeting resident's needs.” During the investigation, the Administrator reported that the resident (R1) was outside for an unknown amount of time between 11pm and 1am. The administrator stated that R1 had fallen out of his wheelchair into a bush with a sprinkler outside, when it was approximately 40 degrees outside, without supervision. The Administrator reported that on the date of the incident 2 of 3 staff scheduled to work arrived for their shift. All staff interviewed reported that R1 was not wearing a pendent, as they just moved in. Of the staff interviewed, they stated that it is difficult to meet the needs of the residents. Substantiated Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099 D. As a result of the resident sustaining an injury, an immediate civil penalty was assessed in the amount of $500.00 on 01/29/2024, on the attached LIC421IM. Appeal rights were provided. An exit interview was conducted. A copy of the report was provided to the facility.the state’s words, verbatim · CDSS document, Jan 29, 2024 · control 59-AS-20231211084559

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Feb 2, 2024

87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs or the physical arrangements of the facility require such additional staff for the provision of adequate services. The requirement is not met as evidence by: Based on observation, interviews and record review, the licensee did not provide adequate care and supervision by leaving a dementia resident unsupervised outside for an extended period of time which poses an immediate Health, Safety, Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 29, 2024

Plan of correction: Licensee agrees to provide training for all direct care and administrative staff on the requirement to seek medical attention timely for residents. Licensee will schedule the training and provide CCL with the training content and signed staff attendance sheet as proof of correction.

Allegation investigated: Staff did not provide residents with an adequate amount of food. Staff did not assist residents with self-administration of medication.

On 10/10/23, Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 04/21/23. LPA Gurriere met with Stacey Baxter, Assistant Administrator, and explained the purpose of the visit. Staff did not provide residents with an adequate amount of food. During the interview process, the assistant administrator and four staff persons were interviewed. Three other staff persons were contacted; however, they did not return the call. The resident (Resident 1) was not interviewed as she is on hospice care and is too advanced in her hospice journey to be interviewed. Documents were received to include the residents Physician Report, Admission Agreement, medications list, care tracking sheet and weight records. continued Unsubstantiated During the investigation, on 05/02/23 Donna Gurriere, LPA conducted a walk through of the kitchen to determine if there was an adequate amount of food. During the visit, it was noted that the cook was providing lunch to include a large slice of chicken, macaroni and cheese and cold slaw. The food was prepared, and appropriate amounts of portions were provided. The residents were having vanilla shakes for dessert. Staff were interviewed and all staff reported that they have observed and felt that there was an appropriate amount of food that was being provided daily to include three meals a day and snacks. Additionally, it was reported that the facility always has additional food to include second helpings, left over foods and anytime meals of grill cheese sandwiches, peanut butter and jelly sandwiches, crackers, etc. It was reported that throughout the day residents are offered snacks to include bananas, pudding, left over desserts and fruits. A resident’s weight records were reviewed, and the records indicated that during the time of January through June 2023, the resident’s weight fluctuated by approximately five pounds. In June 2023 the resident was placed in hospice care and her weight has gone down by 10 pounds, which is understandable since it was reported that the resident is on hospice and at times refuses to eat meals. Due to the information above, CCL finds the allegation to be Unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Staff did not assist residents with self-administration of medication. During the interview process, the assistant administrator and four staff persons were interviewed. Three other staff persons were contacted; however, they did not return the call. The resident was not interviewed as she is on hospice care and is too advanced in her hospice journey to be interviewed. Documents were received to include the residents Physician Report, Admission Agreement, medications list, care tracking sheet and weight records. During the investigation, the staff persons were interviewed, and reported that staff do assist the residents with self-administration of medication. Staff advised that when the medication technician passes the medication to the residents, the medication technicians are to standby the resident to ensure that the resident takes and swallows the medication. Due to the information above, CCL finds the allegation to be Unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.the state’s words, verbatim · CDSS document, Oct 10, 2023 · control 59-AS-20230421145534

Allegation investigated: Facility is operating without an Administrator.

On 10/10/23, Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 04/21/23. LPA Gurriere met with Stacey Baxter, Administrator Assistant and explained the purpose of the visit. The facility is operating without an Administrator. On 04/28/23, Diania Bingham submitted a copy of her administrator certificate to the licensing agency. On 05/01/23 a complaint was received that the facility was operating without an administrator. Ms. Bingham reported to the licensing agency that she would like to be listed as the administrator and the licensing agency accepted her request, effective 04/28/23. Documents were received to include the administrator certificate which was effective 04/28/23 to 04/27/25. Based on information above, the department concluded that the allegation is Unfounded. A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Unfounded continued During the investigative process, two cooks were interviewed to ask if they had provided any type of care and supervision to the residents as alleged. Both cooks stated that they do not and have not provided care. Also, it was alleged that the assistant administrator was providing care to the residents without training. When the assistant administrator was interviewed, she advised that she has provided care and supervision to the residents and that her training included care and supervision courses, plus 10 years as a medication technician. All other staff persons stated that the allegation is not true. Due to the information above, CCL finds the allegation to be Unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.the state’s words, verbatim · CDSS document, Oct 10, 2023 · control 59-AS-20230501082310