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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002775
Report Date: 10/21/2025
Date Signed: 10/22/2025 04:38:59 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
04/10/2025 and conducted by Evaluator Kayla Adkison
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250410131635
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: 23DATE:
10/21/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Bailey Leach, AdministratorTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Allegation: Staff did not prevent residents’ room from being unsanitary.
INVESTIGATION FINDINGS:
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 On October 21, 2025, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility for the purpose of delivering complaint findings. LPA was greeted by Bailey Malagon, Administrator, and explained the purpose of the visit. At the time of the visit, there were 23 residents in the facility and 3 staff providing care.

During the course of the investigation, LPA made observations, conducted interviews, and review records obtained from the facility.

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

DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
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 3
Control Number 59-AS-20250410131635
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: 10/21/2025
NARRATIVE
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Allegation: Staff did not prevent residents’ room from being unsanitary.

It was alleged that staff did not prevent a resident's room from being unsanitary. On April 18, 2025, LPA received photographs of an unspecified resident’s room with what appeared to be feces on the bed and several surfaces. It was alleged that night staff would leave the mess for the following shift to take care of.
The Facility Administrator admitted that a resident had been exhibiting this type of behavior. LPA observed the care notes and doctor’s notes for this resident and observed documentation of the facility reaching out to the primary care physician to report the behavior and to have the resident seen by the doctor for a change in condition. LPA interviewed 4 staff, of which, all noted they knew about the residents’ behaviors; however, all staff stated the mess was cleaned up as soon as it was discovered. One staff member stated the resident’s family had cleaned up the mess before during a visit as they were the first ones to observe the resident after it had occurred.

However, on April 18, 2025, April 22, 2025, and May 27, 2025, during visits to the facility, LPA observed the same resident’s room to smell strongly of urine. The resident’s bedding was saturated with urine and thus unsanitary. During each of these visits, the scent of urine was strong enough to be detected from the hallway outside of the room.

Based on observations, interviews, and record review, 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 9099-D. Exit Interview conducted. A copy of this report and Appeal Rights were provided to Bailey Malagon, Administrator.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 59-AS-20250410131635
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: 10/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation - (a) The facility shall be clean, safe, sanitary and in good repair at all times.
This requirement was not met as evidenced by:
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Licensee/Administrator shall ensure resident's rooms and belongings are kept sanitary and remain odor free. Licensee/Administrator shall create and submit a plan to licensing to address the consistent unsanitary conditions by end of business October 31, 2025.
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Based on observations and interviews conducted, the licensee did not ensure that R1's room was clean, safe, and sanitary on at least three (3) seperate dates, which poses a potential health, safety or personal rights violation.
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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: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3