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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002773
Report Date: 02/20/2025
Date Signed: 02/20/2025 01:10:50 PM

Document Has Been Signed on 02/20/2025 01:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ROSELEAF OROVILLEFACILITY NUMBER:
045002773
ADMINISTRATOR/
DIRECTOR:		BAXTER, STACEYFACILITY TYPE:
740
ADDRESS:1900 20TH STTELEPHONE:
(530) 538-8200
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY: 60CENSUS: 33DATE:
02/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Stacey Baxter - administratorTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
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02/20/2025 09:00 AM Licensing Program Analysts (LPAs) Rebecca Knight and Kayla Adkison arrived at the facility unannounced to conduct a Required-1 Year inspection. LPAs met with administrator Stacey Baxter and administrator in training Jessica Owen and explained the purpose of the visit.

LPAs and staff toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and facility grounds. Staff and resident files were reviewed. All employees requiring background checks are cleared. Medications were reviewed.

There is a schedule of recreational activities planned for the residents. Bedding, linens, and towels for residents were observed and found to be clean and in good repair. There is an adequate supply of toiletries for the residents. Medication is locked in the medication room.

The facility was observed to be at a comfortable temperature. Hot water measured between 105 – 120 degrees F. Common area was clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Bathrooms were clean and in good repair. Kitchen was clean and in good repair. The facility has a second building that contains 3 resident rooms but is not occupied presently. Food appears to be stored and prepared properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. Fire extinguishers fully charged and inspected. Smoke detectors are all operational and are inspected annually by fire marshall and monitored by Foothill Fire Protection continually. There are no pools/bodies of water are on premises. Disaster drills are conducted every six months, the facility has been conducting fire drills every 3 months.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 02/20/2025 01:10 PM - It Cannot Be Edited


Created By: Rebecca Knight On 02/20/2025 at 12:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ROSELEAF OROVILLE
FACILITY NUMBER: 045002773

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 2 of 6 staff files which did not contain First aid certificates.which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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LIcensee agrees to submit completed first aid training certificates for two staff as proof of correction.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lauren Crocker
LICENSING EVALUATOR NAME:Rebecca Knight
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ROSELEAF OROVILLE
FACILITY NUMBER: 045002773
VISIT DATE: 02/20/2025
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LPAs observed the following deficiencies:

During records review LPAs determined that 2 of 6 staff files did not contain First aid certificates.

LPAs observed the following during the tour of the facility: Lower activities room common bathroom sink not draining. Room 9 shower floor soiled. Room 26 bathroom light fixture missing glass cover. Room 26 bathroom fan dirty. Discarded items need to be removed from west side entrance to include motorized wheelchair and mattress. Sun room currently has discarded rental equipment (beds, oxygen cannisters, wheelchairs, walkers) that need to be picked up by rental company. Two window screens need to be re-installed on exterior windows on South side of the building. Weeds need to be removed from gutters over entrance to activity room. Discarded metal table needs to be removed from backyard. Discarded heavy metal doors need to be removed from east side activity area.



Deficiencies are being cited as a result of today’s inspection and are included on the attached LIC809-D forms. California Code of Regulations, (Title 22), is being cited on the attached LIC809D. Appeal rights were provided. Exit interview was conducted and the report was provided to administrator Stacey Baxter.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/20/2025 01:10 PM - It Cannot Be Edited


Created By: Rebecca Knight On 02/20/2025 at 12:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ROSELEAF OROVILLE
FACILITY NUMBER: 045002773

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)

87303 Maintenance and Operation (a) 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 is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in Lower activities room common bathroom sink not draining. Room 9 shower floor soiled. Room 26 bathroom light fixture missing glass cover. Room 26 bathroom fan dirty. Discarded items need to be removed from west side entrance to include motorized wheelchair and mattress. Sun room currently has discarded rental equipment (beds, oxygen cannisters, wheelchairs, walkers) that need to be picked up by rental company. Two window screens need to be re-installed on exterior windows on South side of the building. Weeds need to be removed from gutters overs entrance to activity room. Discarded metal table needs to be removed from backyard. Discarded heavy metal doors need to be removed from east side activity area.which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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Licensee agrees to remove all discraded items, replace light fixture cover in room 26 bathroom, clean bathroom fan in room 26, repair bathroom sink in activities area, clean shower floor in room 9, re-install window screens, ensure gutters are cleaned.

Licensee shall submit a plan to ensure all discarded rental items are removed by rental company.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lauren Crocker
LICENSING EVALUATOR NAME:Rebecca Knight
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
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