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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002773
Report Date: 07/31/2021
Date Signed: 07/31/2021 11:53:42 AM

Document Has Been Signed on 07/31/2021 11:53 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:ROSELEAF OROVILLEFACILITY NUMBER:
045002773
ADMINISTRATOR:BROWN, TERRY LFACILITY TYPE:
740
ADDRESS:1900 20TH STTELEPHONE:
(559) 970-1240
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY: 60CENSUS: 30DATE:
07/31/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Mellisa MillerTIME COMPLETED:
12:00 PM
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On 7/31/21 at 9:05 AM, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced Case Management Health and Safety visit as directed by the department. LPA spoke with Administrator, Terry Brown by phone to announce the visit. LPA met with Medication technician, Mellissa Miller who allowed LPA access to the facility.
Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Additionally, LPA self-screened and temperature checked in the front lobby.

LPA toured the facility inside and out including but not limited to facility dining areas, staff break rooms, kitchen area and common areas. LPA observed that the facility was clean and free of any obstruction of pathways. LPA observed that the facility has all proper and required signs for COVID-19 prevention and safety protocol. LPA observed most sinks had hand washing signs posted. Hand washing areas are supplied with soap and paper towels. LPA observed all staff members to be wearing N-95 masks. All staff self-screened upon entrance and leaving the facility. LPA observed hand sanitizers throughout the facility. LPA reviewed facility's employee screening log. Facility has a 7-day non-perishable and 2-day perishable supply of food.
There are a med tech, 2 staff and a chef working at this time.

LPA reported in and wrote there report outside of the building 10:10-10:55 AM. (Report continued)
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: ROSELEAF OROVILLE
FACILITY NUMBER: 045002773
VISIT DATE: 07/31/2021
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The following was advised:
· Sign in pens have used and sanitized holders;
· LPA provided and recommended use of “COVID-19 Symptom Self-Assessment and Affirmation Questionnaire “;
· All hand washing stations be resupplied as needed;
· Wall mounted hand sanitizers be refilled or removed if not operating;
· Resident’s be encouraged to wear surgical masks, if able to tolerate, while in the community;
· Furniture in common areas be moved or removed as needed to maintain physical distance of six feet minimum;
· The facility’s mitigation plan be readily available to staff;
· Staff break room posted with max capacity for physical distancing;
· Trash cans with lids throughout the facility for disposal of PPE;
· Mask options and fit testing for N-95 use;
· Resident symptoms and temperature checks by conducted and recorded at least once per AM and PM shift;
· Post PPE donning and doffing instructions at PPE stations.

As a result of this visit, no deficiencies were cited.

LPA reviewed the report by phone with Administrator. LPA requested a copy of the current line list for the known four covid positive residents, one suspected positive resident and nine covid positive staff, a copy of the resident and staff rosters be emailed to LPA and regional manager (business card provided).

Exit interview conducted and a copy of report was given.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2021
LIC809 (FAS) - (06/04)
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