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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002775
Report Date: 03/18/2025
Date Signed: 03/26/2025 01:46:37 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
01/23/2025 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 59-AS-20250123105158
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: 31DATE:
03/18/2025
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:DIANIA BINGHAMTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility staff did not seek timely medical attention for resident.
Facility staff did not report change in condition to authorized representative.
Facility staff do not meet the needs of residents in care.
Facility is malodorous.
INVESTIGATION FINDINGS:
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Amended: Unsubstantiated page moved see 03/25/25 9099.

On 03/18/25 Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 10/22/24. LPA Gurriere met with Diania Bingham, Administrator and explained the purpose of the visit.


Facility staff did not seek timely medical attention for resident.

During the interview process, the administrator and seven staff persons were interviewed. Documents were obtained to include resident observations, resident roster, Physician’s Report, Individual Service Plan, Resident’s Quarterly Report and staff names and cell numbers.


continued
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
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 8
Control Number 59-AS-20250123105158
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: 03/18/2025
NARRATIVE
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During the investigation process, and review of the resident’s (Resident 1) observation log, it was reported that on 01/15/25, 01/18/25 and 01/20/25, the resident was complaining of shoulder pain. Staff reported that they advised upper management of the resident’s pain, which was their protocol to have the resident sent out by emergency services. The management did not send the resident out until 01/21/25, which was six days later.

Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard have been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.


Facility staff did not report change in condition to authorized representative.

During the interview process, the administrator and seven staff persons were interviewed. Documents were obtained to include resident observations, resident roster, Physician’s Report, Individual Service Plan, Resident’s Quarterly Report and staff names and cell numbers.

During the investigation process, it was reported that the resident’s (Resident 1) responsible party was not notified of the initial complaint of the resident’s shoulder pain. It was reported that it was at least six days later before the responsible party was notified. The regulations state that 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.

Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard have been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 59-AS-20250123105158
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: 03/18/2025
NARRATIVE
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Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard have been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.

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

DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 59-AS-20250123105158
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: 03/18/2025
NARRATIVE
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The contents of this page has been removed, see LIC 9099 dated 03/25/25.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 8
Control Number 59-AS-20250123105158
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: 03/18/2025
NARRATIVE
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Facility staff do not meet the needs of residents in care.

During the interview process, the administrator and seven staff persons were interviewed. Documents were obtained to include resident observations, resident roster, Physician’s Report, Individual Service Plan, Resident’s Quarterly Report and staff names and cell numbers.

During the investigation process, nearly all staff reported that staff are not meeting the needs of residents in care. It was stated that generally there are two care providers and one medication technician for 30 plus residents. It was reported that frequently a staff person will “call out” meaning not come to work, which then leaves one care provider and one medication technician to take care of 30 plus dementia residents. Staff reported that it is impossible to ensure that all residents are showered on their scheduled shower day and that their needs are not being met.

Part of the allegation included that the resident’s were not seeing a podiatrist. The administrator provided documentation that a person from a clinic comes to the facility quarterly to provide care for the resident’s podiatry needs. The document indicated that approximately 10 residents received services on 01/20/25.

Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard have been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.

Facility is malodorous.



During the interview process, the administrator and seven staff persons were interviewed. Documents were obtained to include resident observations, resident roster, Physician’s Report, Individual Service Plan, Resident’s Quarterly Report and staff names and cell numbers.

During the investigation process, it was reported that residents use the common area toilets and that at times the toilets do get clogged and that there is an odor. Staff stated that sometimes resident’s put in too much paper products and this is part of the reason that the toilets clog up. Staff reported that they are responsible for unclogging the toilets as soon as they can. The administrator reported that if there is a problem that cannot be fixed by the staff, she will call a plumber. It was reported that when the toilets are plugged, it may cause a foul odor.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 59-AS-20250123105158
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: 03/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/19/2025
Section Cited
CCR
87464(d)
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87464 Basic Services - A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources.

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The administrator agrees to write a plan of correction advising how she will avoid this type of citation in the future.
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This requirement was not met as evidenced by: Based on interviews and a review of the resident’s observation log the licensee/administrator did not send the resident out for emergency services. This poses an immediate risk to residents in care.
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Type A
03/19/2025
Section Cited
CCR
87466
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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.
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The administrator agrees to write a plan of correction advising how she will avoid this type of citation in the future.
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This requirement was not met as evidenced by: Based on interviews and a review of the resident’s observation log the licensee/administrator did not notify the resident’s responsible party, as required. This poses a immediate risk to residents in care.
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Repeat violation, $250. civil penalty.
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: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 59-AS-20250123105158
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: 03/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2025
Section Cited
CCR
87464(f)
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Basic Services - Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code Section 1569.2(c).
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The administrator agrees to submit to the licensing agency the Personnel Report (LIC 500) advising how she will meet the needs of the residents by increasing staffing.
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This requirement was not met as evidenced by: Based on interviews and a review of the records, the licensee/administrator did not ensure that residents were receiving their showers as required. This poses a potential risk to residents in care.
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Type B
03/25/2025
Section Cited
CCR
87303(a)
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Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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The administrator agrees to write a plan of correction advising how she will avoid this type of citation in the future.
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This requirement was not met as evidenced by: Based on interviews, the licensee/administrator did not ensure that the facility was without clogged toilets and an odor throughout the facility. This poses a potential risk to residents 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: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 8