Inspection Reports for Roseleaf Gardens

The visit was a case management visit conducted to assess ongoing compliance and follow up on previously identified deficiencies at the facility.

The inspection found that two wings of the facility were malodorous due to three residents regularly refusing showers, which affected other residents. Deficiencies were cited related to failure to provide personal assistance and care as required.

The visit was a Case Management - Legal/Non-compliance meeting held to discuss several compliance issues observed during recent visits and complaints submitted to the department.

The report highlights concerns including the use of coded locking mechanisms on exit doors restricting resident access, staffing levels and training adequacy, and multiple recent deficiencies cited. A compliance plan addressing quality of care, staffing, building oversight, and safety was directed.

The visit was an unannounced follow-up Case Management - Deficiencies Inspection to verify correction of previous deficiencies.

The inspection found multiple Type A deficiencies posing immediate health, safety, or personal rights risks, including locked exit doors with codes, accessible cleaning solutions, missing lightbulb and lampshade, and multiple rooms with bad odors.

The inspection was an unannounced Required-1 Year annual inspection conducted to ensure compliance with licensing requirements and the health and safety of residents.

The facility was generally clean and in good repair with medications secured and food properly stored. However, two resident rooms were odorous, one bathroom was locked and out of order, and there were deficiencies related to criminal record clearance, personnel records, and postural supports.

The inspection visit was an unannounced complaint investigation triggered by allegations received on 01/23/2025 regarding mismanagement of resident supplies, unsafe environment for residents, and facility disrepair.

The investigation included interviews with the administrator and seven staff members and review of relevant documents. All allegations were found to be unsubstantiated due to lack of preponderance of evidence.

The complaint investigation addressed allegations that facility staff mismanaged resident supplies, did not provide a safe environment for residents, and that the facility was in disrepair. After investigation, all allegations were determined to be unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-01-23 regarding allegations of failure to seek timely medical attention, failure to report change in condition to authorized representative, failure to meet residents' needs, and facility malodor.

The investigation substantiated all allegations: staff delayed sending a resident to emergency services by six days; the resident's responsible party was not notified timely of the change in condition; staffing levels were insufficient to meet residents' needs, including showering and podiatry care; and the facility experienced clogged toilets causing malodor. Several violations of California Code of Regulations (Title 22) were cited.

The complaint investigation was substantiated. Allegations included failure to seek timely medical attention, failure to notify authorized representative of condition changes, failure to meet residents' needs, and facility malodor. The preponderance of evidence standard was met for all allegations.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 2024-07-08 regarding resident care issues including lack of regular showers, oral hygiene, unexplained broken ribs, delayed medical attention resulting in sepsis, and neglect resulting in pressure injuries.

The investigation found the initial allegations of lack of bathing, oral hygiene care, unexplained broken ribs, and delayed medical attention with sepsis to be unsubstantiated due to insufficient evidence. However, the allegation of resident neglect resulting in the development of pressure injuries was substantiated, with findings that the facility failed to communicate with the resident's physician or seek alternative medical options after home health care was denied.

The complaint investigation was triggered by allegations received on 07/08/2024 concerning inadequate resident care including failure to provide regular showers, oral hygiene, unexplained broken ribs, failure to seek timely medical attention resulting in sepsis, and neglect causing pressure injuries. The investigation concluded that the first four allegations were unsubstantiated, while the neglect allegation was substantiated.

The inspection was conducted as a Case Management-Incident Inspection following reports of a resident-to-resident altercation and a resident fall.

No deficiencies were cited during the inspection. The facility reported no severe injuries from the altercation, medication changes were made for the aggressive resident, and the resident who fell had no new orders. The Licensing Program Analyst educated the Administrator on accurate incident reporting.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-08-22 alleging inadequate care and supervision, improper incident reporting, unmet incontinence needs, unexplained injuries, and failure to address a resident's change in medical condition.

The investigation substantiated that staff failed to provide adequate care and supervision related to bathing documentation, posing an immediate health and safety risk. Other allegations regarding incident reporting, incontinence care, unexplained injuries, and addressing medical condition changes were unsubstantiated due to insufficient evidence.

The complaint investigation was substantiated for inadequate care and supervision related to bathing. Other allegations including improper incident reporting, unmet incontinence needs, unexplained injuries, and failure to address medical condition changes were unsubstantiated due to insufficient evidence.

An unannounced complaint investigation visit was conducted in response to a complaint received on 2024-07-17 alleging staff neglect resulting in a resident being hospitalized and failure to ensure a resident consumed an appropriate amount of liquid.

The investigation substantiated the allegations that staff neglect resulted in a resident suffering third-degree burns and other serious health issues after being left unsupervised outside for 30 to 90 minutes in temperatures exceeding 100 degrees. The resident required hospitalization and transfer to higher levels of care. The facility was cited for inadequate care and supervision, posing immediate health and safety risks.

The complaint was substantiated. Staff neglect was found to have caused a resident to be hospitalized with severe burns and other complications. The resident was left unsupervised outside in extreme heat, resulting in serious injury. The facility was assessed an immediate civil penalty of $1000 with potential for additional penalties.

The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2024-05-03 alleging overmedication of a resident, failure to report incidents, insufficient staffing, insufficient administrator presence, and inadequate food/liquid provision to residents.

The investigation found no preponderance of evidence to substantiate the allegations. Staff did not document contacting the hospice nurse prior to administering PRN medications, but overmedication could not be proven. Staffing levels, administrator presence, incident reporting, and resident food/liquid provision were found sufficient based on interviews and document reviews. All allegations were unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included overmedication, failure to report incidents, insufficient staffing, insufficient administrator presence, and inadequate food/liquid provision. Interviews with staff and review of records did not support the allegations.

The visit was a case management follow-up on a complaint investigation received on 2024-05-03 regarding documentation of staff contacts with the physician when administering PRN medications.

The investigation found that facility staff failed to document the date and time of each contact with the hospice physician and the physician's directions when administering PRN medications to a resident. The allegation was substantiated based on observations, interviews, and record reviews.

The complaint was substantiated based on the preponderance of evidence standard after investigation of the allegation that staff failed to document physician contacts related to PRN medication administration.

The inspection was conducted as a Case Management-Incident visit following a report that a resident eloped from the facility without staff knowledge on June 30, 2024.

Deficiencies were cited for inadequate supervision of a dementia resident who eloped, and failure to provide an updated medical assessment for a resident with dementia. Civil penalties of $250.00 were assessed.

The visit was complaint-related due to a resident eloping without staff knowledge. Civil penalties were assessed and plans of correction were required.

The visit was an unannounced case management inspection to discuss an incident that occurred on June 30, 2024.

The licensing program analysts arrived to discuss the incident but were unable to meet with the administrator due to evacuations at a sister facility. The incident discussion was postponed to a later date.

The visit was triggered by an incident report related to a complaint or concern. The incident occurred on June 30, 2024. No substantiation status is provided.

An unannounced complaint investigation visit was conducted in response to an allegation that staff were not assisting residents to change clothes regularly.

The allegation was substantiated based on interviews and document reviews. The resident was not assisted with dressing for four days as outlined in their care plan, and documentation of care tasks was inconsistent and sporadic.

The complaint was substantiated. The allegation that staff were not assisting the resident to change clothes regularly was found to be true based on evidence and interviews.

An unannounced complaint investigation visit was conducted in response to a complaint received on 2024-01-30 regarding medication administration, alteration without consent, and inadequate supervision resulting in excessive falls.

The investigation substantiated that staff did not provide medication as prescribed, altered a resident's medication without consent, and failed to provide adequate supervision leading to excessive falls. Documentation review and interviews confirmed the absence of required physician orders and fall risk plans, posing immediate health and safety risks.

The complaint was substantiated based on investigation observations, interviews, and record reviews. Allegations included failure to provide medication as prescribed, unauthorized alteration of medication, and inadequate supervision resulting in excessive falls. The preponderance of evidence standard was met for all allegations.

The inspection was an unannounced 1-Year Required Annual Inspection conducted to ensure the health and safety of residents in care at Roseleaf Gardens facility.

The inspection found several deficiencies including water temperature above required limits in two bathrooms, presence of urine in a bucket in a resident's room, a non-working bathtub, missing medical orders for bed rails in resident files, missing TB tests and first aid training documentation in staff files, lack of fire drills in the past 12 months, and missing 'No Smoking - Oxygen in Use' signage outside a resident's room with oxygen.

The visit was an unannounced complaint investigation triggered by an allegation that staff were not meeting resident's needs.

The investigation substantiated the allegation that staff failed to provide adequate care and supervision, resulting in a dementia resident being left unsupervised outside for an extended period and sustaining an injury. An immediate civil penalty was assessed.

The complaint was substantiated based on the preponderance of evidence standard. The resident was found outside unsupervised between 11pm and 1am, fell from a wheelchair into a bush with a sprinkler, and was exposed to approximately 40-degree weather without supervision. Staff shortages were noted, with only 2 of 3 scheduled staff arriving for the shift.

The inspection visit was conducted to investigate complaints received on 2023-04-21 and 2023-05-01 regarding allegations that the facility was operating without an administrator and that staff without appropriate training were providing care to residents.

The investigation found that the facility was not operating without an administrator as the administrator certificate was submitted and accepted effective 2023-04-28, resulting in the allegation being unfounded. The allegation that staff without appropriate training were providing care was found to be unsubstantiated due to insufficient evidence to prove the violation.

Two complaints were investigated: 1) Facility operating without an administrator, which was found to be unfounded. 2) Staff without appropriate training providing care, which was found to be unsubstantiated due to lack of sufficient evidence.

The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-04-21 alleging that staff did not provide residents with an adequate amount of food and did not assist residents with self-administration of medication.

The investigation found both allegations to be unsubstantiated. Interviews with staff and review of documentation indicated that adequate food was provided, including three meals and snacks, and that staff assisted residents with self-administration of medication by ensuring residents took and swallowed their medication.

The complaint alleged that staff did not provide residents with an adequate amount of food and did not assist residents with self-administration of medication. The investigation included interviews with staff and review of resident records. The resident involved was not interviewed due to being in advanced hospice care. Both allegations were found to be unsubstantiated.

The visit was an unannounced complaint investigation triggered by an allegation that staff did not provide the resident's records to the resident's responsible party.

The investigation found that although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the violation occurred, and the findings were unsubstantiated.

The complaint alleged that staff did not provide resident's records to the resident's responsible party. The findings were unsubstantiated.

The visit was conducted due to a complaint received on 07/11/22 alleging financial issues at the facility. A solvency audit was requested to review the financial status of the facility and related entities.

The licensee was found to lack an adequate financial plan to ensure uninterrupted care and supervision of residents, had inadequate liability insurance coverage, and failed to exercise general supervision over the affairs of the licensed facilities. The facility is not in good financial standing due to negative incomes, overdue payments, and negative equity.

The complaint was substantiated based on investigation observations, interviews, and record reviews. The facility was found to have financial issues including inadequate financial planning, insufficient liability insurance, and poor governance accountability.

The visit was an unannounced Required-1 Year Inspection focusing on the infection control domain to ensure compliance with health and safety regulations.

No immediate health, safety, or personal rights violations were observed during the tour of the facility. The facility was found to be in substantial compliance with infection control standards and no deficiencies were cited.

The visit was an office meeting held via Microsoft Teams to follow up on a previous meeting held on 7/22/2022, discussing topics related to facility operations and compliance.

The meeting covered physical plant conditions, staffing levels to meet resident needs, overall facility operations including consultant roles and staff training, and COVID-19 outbreak status with infection control and visitation guidance. All facilities were reported cleared through local public health.

An office meeting was held on 7/22/2022 via Microsoft Teams to discuss topics including citations issued to Roseleaf Oroville, physical plant issues at Roseleaf Oroville, staffing levels, facility administrator vacancies, and overall operation of all facilities.

The report summarizes discussions about citations issued to Roseleaf Oroville, malfunctioning fire alarm system, inoperable air conditioning and water heater, staffing considerations, and administrator vacancies. Several documents were requested to be submitted by 7/29/2022.

The visit was an unannounced case management visit conducted to tour the facility and discuss relevant forms and protocols.

The Licensing Program Analyst and Regional Manager toured the facility with the Executive Director, completed COVID-19 screening protocols, and found no citations or deficiencies at the time of the visit.

The inspection was an unannounced Required-1 Year Inspection conducted to evaluate infection control compliance at the facility.

The facility was found to be in substantial compliance with infection control requirements. No immediate health, safety, or personal rights violations were observed, and no deficiencies were cited.

The visit was an unannounced case management inspection related to a self-reported incident where a resident ingested a 'Mop Pod' cleaning product. The incident was reported by the facility administrator and involved EMS response and hospital discharge.

The inspection found that cleaning supplies were not stored inaccessible to residents with dementia, posing an immediate health and safety risk. A deficiency was cited for failure to keep cleaning supplies away from residents, specifically one resident who accessed the cleaner pod.

The complaint investigation was triggered by a self-reported incident from the administrator regarding a resident ingesting a 'Mop Pod' on 02/20/2022. The incident was substantiated by hospital discharge paperwork confirming ingestion of a foreign substance.

The visit was a case management visit conducted to deliver an Order to Individual of Immediate Exclusion from all facilities and an Order to Licensee/Facility of Immediate Exclusion From Facility.

The Licensing Program Analyst ensured COVID-19 protocols were followed and informed the Administrator that staff member Pauline Willyard is excluded from the facility and not allowed back.

An unannounced site visit and safety check was conducted as part of Case Management - Health Checks at RoseLeaf Gardens facility.

The Licensing Program Analyst reviewed resident documents and daily logs and determined that residents' needs were being met at the time of the visit. No COVID-19 symptoms were reported among staff or residents, and vaccination rates were noted.

An unannounced site visit and safety check was conducted as part of case management and health checks at RoseLeaf Gardens.

No deficiencies in care were noted after reviewing three random resident files and 602's. Residents generally reported satisfaction with care, meals, and assistance, with minor issues promptly addressed.

Pre-licensing inspection conducted via Facetime due to COVID-19 precautions to evaluate the facility for licensure.

The facility was found to be clean, in good repair, and generally compliant with physical plant and safety requirements. However, the facility's signal system was not in compliance at the time of visit but the administrator was ensuring correction by the next day. No citations were issued during the tele-visit.