045002773-5-2-2025-59-AS-KHOS-DGPPUR-20250515113755

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045002773
Report Date: 05/01/2025
Date Signed: 05/02/2025 11:25:00 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/21/2025 and conducted by Evaluator Rebecca Knight

COMPLAINT CONTROL NUMBER: 59-AS-20250321155659

FACILITY NAME:	ROSELEAF OROVILLE		FACILITY NUMBER:	045002773
ADMINISTRATOR:	BAXTER, STACEY		FACILITY TYPE:	740
ADDRESS:	1900 20TH ST		TELEPHONE:	(530) 538-8200
CITY:	OROVILLE	STATE: CA	ZIP CODE:	95965
CAPACITY:	60	CENSUS: 36	DATE:	05/01/2025
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Stacey Baxter - administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility is not ensuring that an appropriately skilled professional is assisting the resident with injections. - UNSUBSTANTIATED
Facility staff are not dispensing medication as prescribed. - UNSUBSTANTIATED

INVESTIGATION FINDINGS:

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04/28/2025 09:30 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Stacey Baxter. The purpose of this visit was to deliver the results of a complaint investigation.

During the course of the investigation LPA interviewed the administrator, resident, and staff. LPA reviewed the following documents Admission Agreement, Physician’s Report, care plan, MAR, glucose monitoring documentation for 1 resident.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20250321155659

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/01/2025

NARRATIVE

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Facility is not ensuring that an appropriately skilled professional is assisting the resident with injections. - UNSUBSTANTIATED

It was reported that a med tech has been giving Resident 1 (R1) their insulin shots.

LPA reviewed the Medication Administration Record (MAR) for R1 which states that R1 takes 20 ml of insulin daily at bedtime. MAR shows that R1 received their insulin shots every evening. Physicians Report states that R1 requires assistance with medication management.

During staff interviews it was learned that R1 prepares their own insulin dosage and gives themselves their dosage with staff supervision.

Executive Director stated staff assist R1 to dial their insulin pen to the correct dosage and R1 gives themselves their insulin.

It was determined that R1 gives themselves their insulin dosage with staff supervision. This allegation is unsubstantiated.

Facility staff are not dispensing medication as prescribed. - UNSUBSTANTIATED

It was reported that the facility had been giving Resident 1 (R1) insulin without checking their glucose level.

LPA reviewed the Medication Administration Record (MAR) for R1 which states R1 checked their glucose levels four times per day using Blood Glucose Test In Vitro Strip. Physicians Report states that R1 requires assistance with medication management.

5 of 5 staff interviewed stated that R1 takes their own glucose readings with “hand over hand’ assistance from staff.

Executive Director stated that staff hand R1 their glucose meter and R1 takes their own glucose readings. Staff logs the readings in R1’s MAR.

It was determined that R1 has been checking their glucose levels four times per day with assistance from staff. This allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted and a copy of the report was provided to administrator Stacey Baxter.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

LIC9099 (FAS) - (06/04)

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