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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002773
Report Date: 08/14/2025
Date Signed: 08/14/2025 01:25:10 PM

Substantiated


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
07/01/2025 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 59-AS-20250701120437
FACILITY NAME:ROSELEAF OROVILLEFACILITY NUMBER:
045002773
ADMINISTRATOR:BAXTER, STACEYFACILITY TYPE:
740
ADDRESS:1900 20TH STTELEPHONE:
(530) 538-8200
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY:60CENSUS: 27DATE:
08/14/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Stacey Baxter - administratorTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Licensee did not ensure that staff are properly trained.- SUBSTANTIATED
INVESTIGATION FINDINGS:
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08/14/2025 12:00 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Executive Director 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, and 6 staff. The following documents were reviewed: MAR for 1 resident, grocery orders for the month of Jun 2025.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 59-AS-20250701120437
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: 08/14/2025
NARRATIVE
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Licensee did not ensure that staff are properly trained. - SUBSTANTIATED

It was reported that Staff 1 (S1) did not complete training videos and was allowed to administer medications.

Executive Director could not provide LPA with documentation to prove that S1 had completed their required medication training.

Executive Director stated S1 should have received video training and 20 hours on the floor shadowing and hands on training. ED did not have proof that S1 took their medication training test.

It was determined that the facility could not supply proof that S1 had completed their required medication training. This allegation is 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 LIC9099D. Appeal rights were provided. Exit interview conducted and a copy of the report was provided to Executive Director Stacey Baxter.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20250701120437
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/28/2025
Section Cited
CCR
87411(c)(6)
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87411 (c)(6) 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. (6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer. This requirement was not met as evidenced by:
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Licensee agrees to develop a process and plan that outlines how they will ensure that all staff training is documented in staff files. Licensee shall submit this plan to LPA as proof of correction.
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Based on LPA record review the licensee failed to document that Staff 1 (S1) had completed training before being allowed to dispense medications which poses a potential health and safety risk to residents in care.
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POC due 08/28/2025.
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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.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
07/01/2025 and conducted by Evaluator Rebecca Knight
COMPLAINT CONTROL NUMBER: 59-AS-20250701120437

FACILITY NAME:ROSELEAF OROVILLEFACILITY NUMBER:
045002773
ADMINISTRATOR:BAXTER, STACEYFACILITY TYPE:
740
ADDRESS:1900 20TH STTELEPHONE:
(530) 538-8200
CITY:OROVILLESTATE: CAZIP CODE:
95965
CAPACITY:60CENSUS: DATE:
08/14/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Stacey Baxter - administratorTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff did not administer medication as prescribed.- UNSUBSTANTIATED
Licensee did not store an adequate amount of food for residents in care.-UNSUBSTANTIATED
INVESTIGATION FINDINGS:
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08/14/2025 12:00 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Executive Director 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, and 6 staff. The following documents were reviewed: MAR for 1 resident, grocery orders for the month of Jun 2025.

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20250701120437
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: 08/14/2025
NARRATIVE
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Staff did not administer medication as prescribed.- UNSUBSTANTIATED

It was reported that Staff 1 (S1) gave the incorrect dosage of medication to Resident 1 (R1).

LPA reviewed Medication Administration Record (MAR) for R1 for the months of June 2025 when the error was reported to have been made. There were no medication errors listed for R1 on this document.

1 of 5 staff that were interviewed stated that S1 had dispensed the wrong medication to R1. This staff could not provide details concerning which (medication name, date) was dispensed incorrectly to R1. 4 other staff who were interviewed stated they had no knowledge that S1 had dispensed medication incorrectly to R1.

Executive Director stated they had not heard that R1 had been administered the wrong medication dosage.

This allegation is unsubstantiated.

Licensee did not store an adequate amount of food for residents in care. – UNSUBSTANTIATED

It was reported that that there is not enough food stored at the facility and the residents are not given enough food.

LPA reviewed Sysco grocery receipts for the delivery date of 06/03/25 amount $2,410.91, 06/10/25 $1,552.60, 06/17/25 total $1,312.23, 06/24/25 total $1,269.67

Kitchens staff stated that the quantity and quality of the food items that are purchased are good. Kitchen staff stated they follow the menu but occasionally have to substitute some items or ingredients. Care staff stated that the kitchen follows the menu but has to substitute some items because they run out.

Executive Director stated they purchase groceries every Thursday from Sysco. They follow the menu and purchase all supplies for three meals a day and also order supplies for snacks and sandwiches. Sysco delivers the weekly order every Tuesday. The monthly food budget is based on the census, and as the census grows the food budget increases.

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 Executive Director Stacey Baxter.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Rebecca Knight
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5