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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045002775
Report Date: 01/27/2026
Date Signed: 01/29/2026 06:04:34 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
07/15/2025 and conducted by Evaluator Kayla Adkison
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250715091831
FACILITY NAME:ROSELEAF GARDENSFACILITY NUMBER:
045002775
ADMINISTRATOR:OWENS, JESSICAFACILITY TYPE:
740
ADDRESS:2770 SIERRA LADERATELEPHONE:
(530) 895-0800
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:56CENSUS: 25DATE:
01/27/2026
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Bailey Malagon, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not ensure resident was properly positioned in shower chair, resulting in a fall
Staff did not seek medical attention for resident
Staff did not report incident involving resident
INVESTIGATION FINDINGS:
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On January 27, 2026, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced for the purpose of delivering complaint findings. LPA was greeted by Administrator, Bailey Malagon, and explained the purpose of the visit. During the visit, there were 4 staff providing care and 25 residents.

During the course of the investigation, LPA reviewed pertinent documents, conducted interviews, and made observations of the facility.

Continued on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026
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 7
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
07/15/2025 and conducted by Evaluator Kayla Adkison
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250715091831

FACILITY NAME:ROSELEAF GARDENSFACILITY NUMBER:
045002775
ADMINISTRATOR:OWENS, JESSICAFACILITY TYPE:
740
ADDRESS:2770 SIERRA LADERATELEPHONE:
(530) 895-0800
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:56CENSUS: 25DATE:
01/27/2026
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Bailey Malagon, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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9
Staff did not wear gloves when changing residents’ diapers
INVESTIGATION FINDINGS:
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On January 27, 2026, Licensing Program Analyst (LPA) Kayla Adkison arrived at the facility unannounced for the purpose of delivering complaint findings. LPA was greeted by Administrator, Bailey Malagon, and explained the purpose of the visit. During the visit, there were 4 staff providing care and 25 residents.

During the course of the investigation, LPA reviewed pertinent documents, conducted interviews, and made observations of the facility.

Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 59-AS-20250715091831
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: 01/27/2026
NARRATIVE
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Staff did not wear gloves when changing residents’ diapers

It was alleged that the facility had run out of gloves and staff were being directed to simply wash their hands between assisting residents with brief changes.

LPA interviewed six (6) current and former staff members and no staff had any knowledge of a time when the facility was out of gloves, nor had they ever been directed to not use gloves when changing residents briefs. Two (2) staff mentioned that gloves were being kept in the med room at the facility and new staff may have not know the location of supplies

LPA observed a supply order list for the previous three months that showed boxes of gloves being ordered in all sizes for the facility. During an inspection of the facility on July 25, 2025, LPA observed multiple boxes of gloves in the facility for staff use.

Although the allegation may have happened, the preponderance of evidence has not been met, and the allegation is therefore UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided to Administrator, Bailey Malagon.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 59-AS-20250715091831
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: 01/27/2026
NARRATIVE
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Allegation: Staff did not ensure resident was properly positioned in shower chair, resulting in a fall.

It was alleged that during a PM shift on July 13, 2025, a resident (R1) had sustained a fall during a shower while being assisted by three staff members. The resident was not supposed to receive "regular" showers and was instead provided "bed baths" due to R1's bedridden status. Staff reported that the management on shift "insisted" on giving R1 the shower and did not place the resident in the shower chair properly, resulting in R1 falling to the floor and sustaining a cut to their forearm.

Staff were interviewed who confirmed the allegation. LPA reviewed R1's care plan dated July 8, 2025, which stated "Bathing - Two Person Assistance- Bed bath, full assistance needed with bed bath as individual is unable to tolerate showering." LPA observed R1's Care Notes dated July 14, 2025, stating "When assisting care staff with transfer, I (staff) noticed a cut on resident's left arm that is about 1 1/2 long. I asked care staff if she knew what happened to resident she said that she had a fall last night (7/13)."

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.

Allegation: Staff did not seek medical attention for resident.

It was alleged that following R1's fall while in the shower, that staff failed to seek medical attention for the resident.

LPA interviewed staff who confirmed this allegation.

LPA reviewed R1's care notes which indicated no medical attention was sought for R1. Staff that originally attempted to report R1's fall indicated in the Care Notes that they cleaned and bandaged the cut on R1's arm and there were no further concerns. A follow-up comment from managerial staff indicated "Resident did not have a fall on 7/13, please ensure we are documenting correctly and accurately." LPA reviewed all Special Incident Reports submitted by the facility and there were none mentioning R1 sustaining a fall or that any medical attention had been sought for the resident on this date.

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.

Continued on LIC 9099-C
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 59-AS-20250715091831
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: 01/27/2026
NARRATIVE
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Allegation: Staff did not report incident involving resident

It was alleged that staff failed to report the previously mentioned incident to Community Care Licensing (CCL) .

LPA conducted a review of Special Incident Reports submitted to CCL at the time the incident occurred and found no evidence of the facility reporting the circumstances as required.

On October 21, 2025, LPA interviewed Administrator Bailey Malagon who conducted a search of the facilities records and confirmed there were incident reports prepared by staff reporting the previously mentioned incident. Administrator noted there was a Care Note describing the incident and R1's injury, however, a separate staff member provided a follow-up care note denying the allegations ever occurred.

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 Administrator, Bailey Malagon.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 59-AS-20250715091831
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: 01/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/20/2026
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This is evidenced by:
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Administrator agrees to conduct/provide training pertinent to the regulation. Administrator shall submit a signed staff attendance to LPA by end of busness on February 20, 2026.
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Based on observation, interview, and record review, the licensee failed to provide safe accomodations for the resident in that staff did not follow the resident's care plan to have only bed baths resulting in a fall while in the care of staff, which poses a potential health, safety, or personal rights risk to persons in care
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Type B
02/20/2026
Section Cited
CCR
87465(g)
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87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health...
This is evidenced by:
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Administrator agrees to conduct/provide training pertinent to the regulation. Administrator shall submit a signed staff attendance to LPA by end of busness on February 20, 2026.
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Based on observation, interview, and record review, the licensee failed to seek medical assistance for the resdient after a fall and sustained injury,
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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: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 59-AS-20250715091831
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: 01/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/20/2026
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below (D) Any incident which threatens the welfare, safety or health of any resident.
This is evidenced by:
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Administrator agrees to conduct/provide training pertinent to the regulation. Administrator shall submit an agenda of this training and a signed staff attendance to LPA by end of busness on February 20, 2026.
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Based on Observation, Interview, and Record Review, the licensee/administrator failed to report an incident in which R1's welfare was threatened, which poses a potential health, safety, or 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: Kayla Adkison
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7