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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002775
Report Date: 10/29/2024
Date Signed: 10/29/2024 10:17:49 AM

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
07/17/2024 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 59-AS-20240717115839
FACILITY NAME:ROSELEAF GARDENSFACILITY NUMBER:
045002775
ADMINISTRATOR:BINGHAM, DIANIAFACILITY TYPE:
740
ADDRESS:2770 SIERRA LADERATELEPHONE:
(530) 895-0800
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:56CENSUS: 34DATE:
10/29/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:STACEY BAXTERTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff neglect resulted in a resident to be hospitalized.
Staff did not ensure a resident consumed an appropriate amount of liquid.
INVESTIGATION FINDINGS:
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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
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
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 4
Control Number 59-AS-20240717115839
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 GARDENS
FACILITY NUMBER: 045002775
VISIT DATE: 10/29/2024
NARRATIVE
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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.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 59-AS-20240717115839
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 GARDENS
FACILITY NUMBER: 045002775
VISIT DATE: 10/29/2024
NARRATIVE
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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.


SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 59-AS-20240717115839
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 GARDENS
FACILITY NUMBER: 045002775
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/30/2024
Section Cited
CCR
87411(a)
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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:
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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.
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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.
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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.
Request Denied
Type A
10/30/2024
Section Cited
CCR
87705(c)(3)(A)
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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.
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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.
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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.
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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: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4