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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002775
Report Date: 11/13/2024
Date Signed: 11/13/2024 09:48:52 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
08/22/2024 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 59-AS-20240822114312
FACILITY NAME:ROSELEAF GARDENSFACILITY NUMBER:
045002775
ADMINISTRATOR:BAXTER, STACYFACILITY TYPE:
740
ADDRESS:2770 SIERRA LADERATELEPHONE:
(530) 895-0800
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:56CENSUS: 37DATE:
11/13/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Resident Services Director, Don DanielsTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff did not provide adequate care and supervision to a resident
INVESTIGATION FINDINGS:
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On November 13, 2024 at approximately 08:30 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Roseleaf Gardens for the purpose of delivering complaint findings. LPA was greeted at the door by Resident Services Director, Don Daniels, and was granted access into the facility.

During the course of the investigation, LPA reviewed facility records, resident records and interviewed staff. Resident could not be interviewed.

Complaint alleges that Staff did not provide adequate care and supervision to a resident. Based on an observation of facility records and an interview that was conducted with the Administrator via email, the preponderance of evidence standard has been met. LPA reviewed the Care Plan and observed the document to reflect that the facility would assist with bathing at a moderate level on Wednesdays and Fridays. (Report continued on LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
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 5
Control Number 59-AS-20240822114312
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: 11/13/2024
NARRATIVE
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During a review of facility care notes, LPA observed that on Friday, July 12, 2024, and Wednesday, July 17, 2024, the bathing was not documented as being completed with no proof that the resident ever denied those showers. Furthermore, On October 23, 2024, LPA conducted an interview with the Administrator via email and learned that the facility has no corroborating evidence to support that the resident denied the showers during said dates (See LIC 9099D). LPA educated the Administrator on the importance of ensuring that Care and Supervision are being given to all residents in care at the facility as outlined in Title 22 Regulation and Health and Safety Code §1569.2.

Deficiencies cited from the Health and Safety Code. Appeal rights were provided. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in Civil Penalties. Exit interview was conducted, and a copy of this report was signed and given to the Resident Services Director along with Appeal Rights.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20240822114312
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: 11/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/14/2024
Section Cited
HSC
1569.2
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Health and Safety Code §1569.2

(c) “Care and supervision” means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care.

This requirement was not met as evidenced by:
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Licensee/Administrator to submit an LIC 9098 understanding of the Health and Safety Code Regulation. In addition, Licensee and Administrator shall conduct staff training outlining the regulations surrounding Care and Supervision. Licensee/Administrator shall provide a statement on how future compliance will be met.
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Based on an observation of facility records and an interview with the Administrator, the facility Care Notes reflected that the bathing was not documented as being completed with no proof that the resident ever denied the showers. LPA conducted an interview with the Administrator via email and learned that the facility has no corroborating evidence to support that the resident denied the showers during said dates which is an immeidate health, safety and personal rights risk to the residents in care.
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POC due date: November 14, 2024
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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: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
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
08/22/2024 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 59-AS-20240822114312

FACILITY NAME:ROSELEAF GARDENSFACILITY NUMBER:
045002775
ADMINISTRATOR:BAXTER, STACYFACILITY TYPE:
740
ADDRESS:2770 SIERRA LADERATELEPHONE:
(530) 895-0800
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:56CENSUS: 37DATE:
11/13/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Resident Services Director, Don DanielsTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff did not properly report incidents involving a resident
Staff did not meet a resident's incontinence needs
Resident sustained unexplained injuries while in care
Staff did not address a resident's change in medical condition
INVESTIGATION FINDINGS:
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On November 13, 2024 at approximately 08:30 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Roseleaf Gardens for the purpose of delivering complaint findings. LPA was greeted at the door by Resident Services Director, Don Daniels, and was granted access into the facility.

During the course of the investigation, LPA reviewed facility records, resident records and interviewed staff. Resident could not be interviewed.

Complaint alleges that Staff did not properly report incidents involving a resident. Based on interviews that were conducted and an observation of a facility incident report dated for August 17, 2024, LPA learned that the facility reported this incident as outlined in Title 22 Regulations. Furthermore, LPA could not corroborate the allegation. (Report continued on LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
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-20240822114312
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: 11/13/2024
NARRATIVE
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Complaint alleges that Staff did not meet a resident's incontinence needs. Based on interviews that were conducted, LPA received inconsistent statements throughout the course of the investigation. LPA reviewed the LIC 602 which revealed that the resident does not make it to the bathroom on time. During this review, it is noted on the LIC 602 that the resident can care for toileting needs. Furthermore, LPA could not corroborate the above allegation due to insufficient evidence.

Complaint alleges that Resident sustained unexplained injuries while in care. Based on interviews that were conducted, LPA received inconsistent statements throughout the course of the investigation. LPA reviewed the Hospital Notes and observed notations that the resident has had two unwitnessed falls at the facility. Furthermore, LPA could not corroborate the above allegation due to insufficient evidence.

Complaint alleges that Staff did not address a resident's change in medical condition. Based on interviews that were conducted, LPA received inconsistent statements throughout the course of the investigation. LPA reviewed the Hospital Notes and observed notations that the resident has decreased appetite and that a higher level of care is possibly needed for the resident. During the hospital evaluation, the attending doctor suggested 24-hour supervision/care for the resident and that an assisted living environment might not be suitable for the resident. Furthermore, LPA could not corroborate the above allegation due to insufficient evidence.

A finding that the complaint allegations of Staff did not properly report incidents involving a resident, Staff did not meet a resident's incontinence needs, Resident sustained unexplained injuries while in care and Staff did not address a resident's change in medical condition are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Resident Services Director.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5