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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002775
Report Date: 04/08/2026
Date Signed: 04/08/2026 05:20:34 PM

Document Has Been Signed on 04/08/2026 05:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ROSELEAF GARDENSFACILITY NUMBER:
045002775
ADMINISTRATOR/
DIRECTOR:		HAWKINS, GRACEFACILITY TYPE:
740
ADDRESS:2770 SIERRA LADERATELEPHONE:
(530) 895-0800
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY: 56CENSUS: 26DATE:
04/08/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Grace Hawkins, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On April 8, 2026, Licensing Program Analyst (LPA) Kayla Adkison and Licensing Program Manager (LPM) arrived at the facility unannounced to conduct a Required Annual Inspection. LPA met with Administrative Assistant (AA) Lillyana Vaughn, and explained the purpose of the visit. LPA spoke with Administrator Grace Hawkins via telephone and confirmed AA would proceed with completing the inspection

During the inspection, there were 26 residents and 5 (five) staff providing direct care. LPA observed residents having lunch, watching television, listening to musical performer, and participating in a physical activity with the Activities Coordinator.

LPA, LPM and AA toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to: common areas, five (5) resident bedrooms and bathrooms, courtyard, kitchen, and storage areas. LPA observed two common bathrooms in need of cleaning. LPA observed the alarm for one exterior door to be turned off or inoperable. LPA noted in two (2) bedrooms, resident's beds were placed in a position where residents were unable to reach their emergency pull cords in the event the cord was dropped or not placed directly nest to the resident. LPA observed one exterior exit door to be blocked by the presence of a hoyer lift and resident wheelchair.

LPA observed each bedroom to have the required furnishings and working lights. LPA observed the facility to be at a comfortable temperature. LPA observed a calendar of activities posted for residents to view. The facility has a 2-day perishable and a 7-day non-perishable amount of food. All residents requiring a special diet are posted for kitchen staff to review. LPA observed all medications, sharps, and cleaning supplies to be locked away and inaccessible to clients in care.

Continued on LIC 809 - C
NAME OF LICENSING PROGRAM MANAGER: Lauren Crocker
NAME OF LICENSING PROGRAM ANALYST: Kayla Adkison
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 9
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/08/2026
NARRATIVE
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LPA observed (3) three fire extinguishers which were last inspected in January 2026. Smoke detectors and carbon monoxide detectors were observed and found to be in working condition. AA was unable to provide proof of the facility conducting emergency drills.

LPA reviewed a total of six (6) resident files and five (5) staff files. One (1) staff file and one (1) residnet file were missing record of a negative tuberculosis test. All staff are fingerprint cleared and associated to the facility. All first aid and CPR training was current. Administrator's certificate is current.

LPA requested a copy of the most recent LIC 500, current liability insurance, and the facility's emergency disaster plan be forwarded to LPA by end of business on April 10, 2026

Deficiencies are being cited in compliance with Title 22 of California Code of Regulations (see attached LIC 809-D). Exit interview conducted. A copy of this report, and Appeal Rights, were provided to Administrator, via email.
NAME OF LICENSING PROGRAM MANAGER: Lauren Crocker
NAME OF LICENSING PROGRAM ANALYST: Kayla Adkison
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 04/08/2026 05:20 PM - It Cannot Be Edited


Created By: Kayla Adkison On 04/08/2026 at 02:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ROSELEAF GARDENS
FACILITY NUMBER: 045002775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that (1) one exterior exit was blocked by a hoyer life and a resident wheelchair which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/09/2026
Plan of Correction
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Licensee/Administrator shall ensure all exits are free of obstruction immedaitely. LPA shall return at a later date to complete this Plan of Correction.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Lauren Crocker
NAME OF LICENSING PROGRAM MANAGER:
Kayla Adkison
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2026


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 04/08/2026 05:20 PM - It Cannot Be Edited


Created By: Kayla Adkison On 04/08/2026 at 02:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ROSELEAF GARDENS
FACILITY NUMBER: 045002775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in that two (2) bathrooms were dirty with dirt in unused showers, visable dirty floors in walk-in showers, and dirty fingerprints on doors/doorjams. Additionally, one (1) exterior door alarm was not sounding and needed the batteries to be replaced, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2026
Plan of Correction
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Licensee/Administrator shall ensure the facility is clean and in good repair at all times. LPA shall return at a later day to complete this Plan of Correction (POC)
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lauren Crocker
NAME OF LICENSING PROGRAM MANAGER:
Kayla Adkison
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2026


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 04/08/2026 05:20 PM - It Cannot Be Edited


Created By: Kayla Adkison On 04/08/2026 at 02:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ROSELEAF GARDENS
FACILITY NUMBER: 045002775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in one (1) out of six (6) staff files did not contain proof of a negative tuberculosis test which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2026
Plan of Correction
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Licensee/Administrator shall have staff member complete a tuberculosis exam and submit negative results to LPA via email by end of busines on April 29, 2026

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lauren Crocker
NAME OF LICENSING PROGRAM MANAGER:
Kayla Adkison
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2026


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 04/08/2026 05:20 PM - It Cannot Be Edited


Created By: Kayla Adkison On 04/08/2026 at 02:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ROSELEAF GARDENS
FACILITY NUMBER: 045002775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one (1) out ofsix (6) resident files did not have record of a negative tuberculosis exam which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2026
Plan of Correction
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Licensee/Administrator shall submit proof of residents negative tb test to LPA via email by end of business on APril 29, 2026.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lauren Crocker
NAME OF LICENSING PROGRAM MANAGER:
Kayla Adkison
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2026


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 04/08/2026 05:20 PM - It Cannot Be Edited


Created By: Kayla Adkison On 04/08/2026 at 03:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ROSELEAF GARDENS
FACILITY NUMBER: 045002775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in that LPA observed (2) two resdient beds positioned away from room pull cords so that residents were unable to reach them in case of an emergency which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2026
Plan of Correction
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2
3
4
LIcensee/Administrator shall submit a plan of how staff shall ensure all residents have access to pull cords in resident rooms. Plan shall be submitted to Licensing by end of business 04/10/2025
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lauren Crocker
NAME OF LICENSING PROGRAM MANAGER:
Kayla Adkison
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2026


LIC809 (FAS) - (06/04)
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