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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002775
Report Date: 02/12/2025
Date Signed: 02/12/2025 01:56:34 PM

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
07/08/2024 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 59-AS-20240708155440
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:
02/12/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Stacey BaxterTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff is not providing regular showers or bathing to resident
Staff is not providing oral hygiene care to resident.
Resident admitted to the hospital with unexplained broken ribs
Staff failed to seek medical attention in a timely manor resulting in resident being admitted to the hospital with sepsis

INVESTIGATION FINDINGS:
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On February 12, 2024 at approximately 01:00 PM, 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 Administrator, Stacey Baxter, and was granted access into the facility.

During the course of the investigation, LPA Sarangi interviewed staff members, witnesses and the Long-Term Care Ombudsman (LTCO) assigned to the facility. In addition, LPA reviewed the resident roster and toured the facility. The Departments Investigations Branch Investigator interviewed staff members and witnesses. In addition, the Investigator reviewed medical records and facility records.

Complaint alleges that Staff is not providing regular showers or bathing to resident. Based on interviews that were conducted, LPA could not prove or disprove the allegation occurred. Furthermore, LPA received inconsistent statements as it relates to the allegation. 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: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
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-20240708155440
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: 02/12/2025
NARRATIVE
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Complaint alleges that Staff is not providing oral hygiene care to resident. Based on interviews that were conducted, LPA could not prove or disprove the allegation occurred. LPA conducted an interview with a witness and learned that the facility provided care to the resident as it relates to oral hygiene. Furthermore, LPA conducted an additional interview with the Long Term Care Ombudsman (LTCO) and learned that the facility was giving the best to care for the resident even though the resident had underlying health conditions. LPA could not corroborate the allegation.

Complaint alleges that Resident admitted to the hospital with unexplained broken ribs. The Departments Investigations Branch Investigator, Blatnick reviewed hospital records and conducted an interview with a facility staff member. During the interview, the Department learned that the resident fell during a transfer from the bed to the wheelchair. It is noted that the residents’ knees buckled causing the resident to fall on the floor and sustain a laceration to the forehead. Resident was subsequently transferred to the hospital where resident received three sutures and a skin tear on the left elbow. Investigator Blatnick reviewed the medical records which noted no fractures. Facility staff did not know how the resident could have sustained a broken rib. The Department could not corroborate the allegation.

Complaint alleges Staff failed to seek medical attention in a timely manor resulting in resident being admitted to the hospital with sepsis. The Departments Investigations Branch Investigator, Blatnick reviewed hospital records and conducted an interview with a facility staff member. During interviews with facility staff, it was revealed that the resident was sent to the hospital immediately after showing signs of a change of condition. Investigator Blatnick reviewed the medical records which did not indicate that the resident had sepsis or severe changes in health. After the resident returned to the facility, staff at the facility noted changes but nothing that warranted a hospital visit. During observation of the resident, staff observed the resident to be less mobile and more depressed. Resident was subsequently hospitalized due to paleness of the skin and a fever. The Department could not corroborate the allegation.

A finding that the complaint allegations of Staff is not providing regular showers or bathing to resident, Staff is not providing oral hygiene care to resident, Resident admitted to the hospital with unexplained broken ribs and Staff failed to seek medical attention in a timely manor resulting in resident being admitted to the hospital with sepsis 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 allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Administrator.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 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
07/08/2024 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 59-AS-20240708155440

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:
02/12/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Staci BaxterTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Resident was neglected resulting in the development of pressure injuries while living at the facility.
INVESTIGATION FINDINGS:
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On February 12, 2024 at approximately 01:15 PM, 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 Administrator, Stacey Baxter, and was granted access into the facility.

Department of Social Services-Community Care Licensing Division-Investigations Branch, Investigator Blatnick obtained and reviewed records, interviewed staff members and witnesses. In addition, the Investigator reviewed medical records and facility records.

Complaint alleges that Resident was neglected resulting in the development of pressure injuries while living at the facility. The Departments Investigations Branch Investigator, Blatnick reviewed hospital records and conducted an interview with a facility staff member.

(Report continued on LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 59-AS-20240708155440
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: 02/12/2025
NARRATIVE
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During interviews with facility staff, the Department learned that the resident was admitted to the Hospital with an unstageable pressure injury on the coccyx and an unstageable pressure injury on the heal of the resident. Staff observed the pressure injury and notified the Administrator and the Residential Care Coordinator. Administrator reported this to the Primary Care Physician who in turn referred the resident to Home Health. The resident’s insurance was denied for home health. The Administrator was unable to indicate what the facility did to address the wound after the home health was denied other than putting medical honey on it and cleaning it daily. The facility did not seek any other medical options when they found out home health was being denied. During an interview with the doctor, the doctor informed Investigator Blatnick of not being aware of the residents’ pressure injuries. In addition, the doctor was never sent a fax by the facility regarding the injury. The facility provided no proof or documentation that they had notified the doctor or home health. Facility staff described the wound as “small and red” but when resident presented to the Hospital it was an unstageable wound (See LIC 9099D).

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. LPA advised the Administrator that the Department may seek an Enhanced Civil Penalty due to the nature of the allegation. Exit interview was conducted, and a copy of this report was signed and given to the Administrator along with Appeal Rights.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20240708155440
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: 02/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/13/2025
Section Cited
CCR
87466
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87466 Observation of the Resident:

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

This requirement was not met as evidenced by:
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Licensee/Administrator shall conduct staff training and provide proof of that training to Community Care Licensing. In addition, Licensee/Administrator shall fill out an LIC 9098-Self-Certification understanding of the regulation.
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Based on observation of records and interviews that were conducted by the Department of Social Services-Community Care Licensing Division-Investigations Branch, Investigator Blatnick, the facility did not seek any other medical options or communicate with the doctor regarding the resident’s condition which presents an immediate health, safety, and personal rights risk to the residents in care.
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Licensee/Administrator shall also provide a statement on how future compliance will be met.

POC due date February 13, 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: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5