Deficiencies (last 6 years)
Deficiencies (over 6 years)
13.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
245% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
36
27
18
9
0
Census
Latest occupancy rate
50% occupied
Based on a March 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 28
Capacity: 56
Deficiencies: 1
Date: Mar 23, 2026
Visit Reason
The inspection visit was an unannounced complaint investigation conducted due to a complaint received on March 13, 2026, regarding the facility's phone number being disconnected causing communication issues.
Complaint Details
The complaint alleged that the facility phone number had been disconnected causing communication issues. The allegation was substantiated based on evidence including calls to listed phone numbers and interviews with staff and the administrator.
Findings
The investigation substantiated that the facility's phone number listed on the website was disconnected, preventing families and the public from contacting residents. The facility was found to have unreliable and incorrectly functioning telephone service, posing a potential health, safety, and personal rights risk to residents.
Deficiencies (1)
Failure to ensure the facility had reliable and correctly functioning telephone service, preventing families from contacting residents.
Report Facts
Capacity: 56
Census: 28
Plan of Correction Due Date: Apr 20, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Adkison | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Grace Hawkins | Administrator | Facility administrator interviewed during the investigation |
| Lauren Crocker | Supervisor | Supervisor overseeing the complaint investigation |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 56
Deficiencies: 0
Date: Mar 23, 2026
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2025-07-23 regarding allegations of resident neglect resulting in wound injuries.
Complaint Details
The complaint alleged that a resident sustained bilateral foot wounds caused by a fungal infection due to staff neglect. The resident was unable to provide a statement. After reviewing records and interviews, the allegation was unsubstantiated.
Findings
The investigation found that it was unclear if staff neglect resulted in the resident's wounds. The allegation was determined to be unsubstantiated due to insufficient preponderance of evidence.
Report Facts
Residents present: 28
Total capacity: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Adkison | Licensing Program Analyst | Conducted the complaint investigation and visit |
| Amanda Harb | Resident Care Coordinator | Met with the investigator during the visit |
| Lauren Crocker | Supervisor | Supervisor overseeing the investigation |
| Jessica Owens | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 56
Deficiencies: 3
Date: Mar 23, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-10-16 regarding staffing, training, and incident reporting issues at Roseleaf Gardens facility.
Complaint Details
The complaint investigation was substantiated. Allegations included insufficient staffing, inadequate staff training, and failure to report incidents. The facility was found to have 28 residents and 4 staff during the visit. The complaint control number is 59-AS-20251016114017. The investigation involved interviews, document reviews, and observations. Some allegations such as failure to clean biohazards, not providing new chuck pads, leaving residents in soiled briefs, delayed assistance, and multiple falls were unsubstantiated.
Findings
The investigation substantiated three allegations: insufficient staffing to provide care and supervision, lack of proper staff training including CPR and First Aid, and failure to report serious incidents to licensing. Several other allegations related to biohazard cleaning, provision of new chuck pads, timely assistance, and resident falls were found unsubstantiated.
Deficiencies (3)
Facility staff was insufficient in numbers to properly care for residents.
Staff did not have required current CPR and First Aid training.
Facility failed to report a resident death and other serious incidents to licensing within required timeframe.
Report Facts
Residents present: 28
Total licensed capacity: 56
Staff present: 4
Staff files reviewed: 3
Staff without current CPR training: 2
Staff without current First Aid training: 1
Unreported incidents: 6
Resident falls: 5
Residents with falls: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Adkison | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Amanda Harb | Resident Care Coordinator | Met with Licensing Program Analyst during inspection and provided information |
| Jessica Owens | Administrator | Facility administrator at time of inspection |
| Bailey Malagon | Administrator | Administrator interviewed during October 21, 2025 visit regarding incident reporting |
| Grace Hawkins | Administrator | Administrator who received exit interview and report copy |
| Lauren Crocker | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 25
Capacity: 56
Deficiencies: 1
Date: Jan 27, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 2025-06-13 regarding staff not seeking medical attention timely, residents lacking access to personal hygiene items, and failure to meet incontinence needs of residents.
Complaint Details
The complaint investigation addressed three allegations: 1) staff did not seek medical attention in a timely manner, 2) residents lacked access to personal hygiene items, and 3) the facility was not meeting incontinence needs of residents. The first two allegations were unsubstantiated due to insufficient evidence, while the third was substantiated based on observations, interviews, and record review.
Findings
Two allegations were found unsubstantiated: staff not seeking timely medical attention and residents lacking access to personal hygiene items. One allegation was substantiated: the facility failed to meet incontinence needs of residents, with evidence of residents left in soiled briefs for extended periods and strong urine odors in the facility.
Deficiencies (1)
Licensee did not ensure that incontinence needs of residents were met; residents were found soaked through their bedding at shift changes and the facility smelled of urine, posing potential health, safety, or personal rights risks.
Report Facts
Staff providing care: 4
Residents present: 25
Deficiency POC due date: Feb 6, 2026
Staff interviewed: 6
Staff observed residents left in soiled briefs: 4
Staff stating facility policy to check residents hourly: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Adkison | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bailey Malagon | Administrator | Facility administrator met with the evaluator and received the report |
| Jessica Owens | Administrator | Named as facility administrator in report header |
Inspection Report
Complaint Investigation
Census: 25
Capacity: 56
Deficiencies: 3
Date: Jan 27, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2025-07-15 regarding allegations of staff negligence and failure to report incidents involving residents.
Complaint Details
The complaint investigation was substantiated based on observations, interviews, and record reviews. The allegations included improper positioning of a resident in a shower chair causing a fall, failure to seek medical attention post-fall, and failure to report the incident to licensing authorities. One allegation about staff not wearing gloves was unsubstantiated.
Findings
The investigation substantiated three allegations: staff did not properly position a resident in a shower chair resulting in a fall, staff failed to seek medical attention for the resident after the fall, and staff failed to report the incident to Community Care Licensing. One allegation regarding staff not wearing gloves when changing residents' diapers was unsubstantiated.
Deficiencies (3)
Failed to provide safe accommodations by not following resident's care plan, resulting in a fall.
Failed to immediately seek medical assistance for a resident after a fall and injury.
Failed to report an incident threatening resident's welfare to the licensing agency within required timeframe.
Report Facts
Capacity: 56
Census: 25
Staff providing care: 4
Deficiencies cited: 3
Plan of Correction Due Date: Feb 20, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bailey Malagon | Administrator | Met with during inspection and involved in incident reporting |
| Kayla Adkison | Licensing Program Analyst | Evaluator conducting the complaint investigation |
| Lauren Crocker | Supervisor | Supervisor overseeing the licensing evaluation |
| Jessica Owens | Administrator | Named as facility administrator in report header |
Inspection Report
Complaint Investigation
Census: 25
Capacity: 56
Deficiencies: 1
Date: Jan 27, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility failed to meet a resident's needs in a timely manner.
Complaint Details
The complaint alleged that on October 8, 2025, staff left a resident unattended in the bathroom for about 1.5 hours after assisting them to sit down, during which the resident fell and hit their head. The resident verbally called for assistance but no staff returned. The resident did not use the bathroom's pull cord as they were told it did not work. The allegation was substantiated based on interviews, observations, and record review.
Findings
The investigation substantiated that staff left a resident unattended in the bathroom for approximately 1.5 hours, resulting in the resident falling and sustaining a head injury. The facility failed to follow the resident's care plan for hands-on toileting assistance, posing a potential health and safety risk.
Deficiencies (1)
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. The licensee failed to meet the resident's needs by not following the care plan and leaving the resident unattended for approximately 1.5 hours, resulting in a fall and injury.
Report Facts
Capacity: 56
Census: 25
Staff on duty: 4
Plan of Correction Due Date: POC due date is February 2, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Adkison | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bailey Malagon | Administrator | Facility administrator who was present during the investigation and received the report |
Inspection Report
Follow-Up
Census: 24
Capacity: 56
Deficiencies: 0
Date: Jan 8, 2026
Visit Reason
The visit was an office meeting held as a follow-up to a Non-Compliance Conference conducted on June 30, 2025, to discuss the facility's response to previously identified issues and new concerns brought to the Department's attention.
Findings
The meeting covered financial concerns including late fees and unpaid bills, maintenance issues at an additional facility, administrator turnover, and reporting requirements. No deficiencies were cited as a result of this meeting.
Report Facts
Capacity: 56
Census: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bailey Malagon | Administrator | Facility representative present during the meeting |
| Mark Cimino | Consultant | Facility representative present during the meeting |
| Rajesh Rao | Managing Member | Facility representative present during the meeting |
| Sridhar Nagunuri | Managing Member | Facility representative present during the meeting |
| Ramaprasad Samudrala | Managing Member | Facility representative present during the meeting |
Inspection Report
Complaint Investigation
Census: 23
Capacity: 56
Deficiencies: 1
Date: Oct 21, 2025
Visit Reason
The visit was an unannounced complaint investigation triggered by a complaint received on 2025-04-10 alleging that staff did not prevent residents’ room from being unsanitary.
Complaint Details
The complaint was substantiated. It involved allegations that staff did not prevent a resident's room from being unsanitary, including feces on the bed and surfaces and urine saturation and odor on multiple dates. The preponderance of evidence standard was met.
Findings
The investigation found that a resident's room was unsanitary on multiple occasions, with bedding saturated with urine and a strong odor detected. Staff acknowledged the resident's behavior and stated the mess was cleaned promptly, but observations confirmed unsanitary conditions. The allegation was substantiated.
Deficiencies (1)
The facility did not ensure that a resident's room was clean, safe, and sanitary on at least three separate dates, posing a potential health, safety, or personal rights violation.
Report Facts
Capacity: 56
Census: 23
Plan of Correction Due Date: Oct 31, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Adkison | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bailey Leach | Administrator | Facility administrator met during the visit and received the report |
| Lauren Crocker | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 23
Capacity: 56
Deficiencies: 1
Date: Oct 21, 2025
Visit Reason
The inspection visit was an unannounced complaint investigation triggered by an allegation that the facility's emergency signal system was inoperable.
Complaint Details
The complaint alleging the facility signal system was inoperable was substantiated based on observations and interviews during the unannounced visit.
Findings
The investigation found that the facility's emergency pull cords were operable but the pagers for the call system were missing or inoperable, causing delays in staff response. The facility temporarily assigned staff to monitor alerts and ordered new pagers to be delivered.
Deficiencies (1)
Facility failed to ensure the emergency signal system was operable, posing an immediate health, safety, or personal rights violation.
Report Facts
Residents present: 23
Total capacity: 56
New pagers ordered: 5
Plan of Correction due date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Adkison | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bailey Malagon | Administrator | Facility administrator involved in the investigation and exit interview |
| Lauren Crocker | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 26
Capacity: 56
Deficiencies: 0
Date: Sep 30, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 2025-04-10 regarding resident care issues at Roseleaf Gardens facility.
Complaint Details
The complaint involved three allegations: 1) staff left residents in soiled diapers for a long period, 2) staff did not seek medical attention in a timely manner after a resident fall, and 3) staff did not report an incident to licensing. The first allegation was unsubstantiated, and the latter two were unfounded based on investigation findings and documentation.
Findings
The investigation found the allegation that staff left residents in soiled diapers for a long period to be unsubstantiated due to lack of evidence. Allegations that staff did not seek medical attention timely and failed to report an incident to licensing were found to be unfounded based on incident reports and documentation.
Report Facts
Residents present: 26
Licensed capacity: 56
Staff present: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kayla Adkison | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Amanda Harb | Residential Care Coordinator | Met with Licensing Program Analyst during the visit and received report |
| Diania Bingham | Administrator | Facility administrator named in the report |
| Lauren Crocker | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Census: 29
Capacity: 56
Deficiencies: 1
Date: Jul 30, 2025
Visit Reason
The visit was a case management visit conducted to assess deficiencies related to resident care and facility conditions, specifically addressing issues of resident refusal of basic services and resulting malodorous conditions in parts of the facility.
Findings
The inspection found that three residents regularly refused showers, causing malodorous conditions in two wings of the facility, which posed an immediate health, safety, or personal rights risk to persons in care. Deficiencies were cited under Title 22 of California Code of Regulations.
Deficiencies (1)
Three residents in the facility are refusing showers, causing specific wings of the facility to be malodorous, which poses an immediate health, safety or personal rights risk to persons in care.
Report Facts
Residents refusing showers: 3
Facility wings affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Owen | Administrator | Met with Licensing Program Analyst and Manager during inspection; named in deficiency discussion |
| Kayla Adkison | Licensing Program Analyst | Conducted inspection and signed report |
| Lauren Crocker | Licensing Program Manager | Conducted inspection and signed report |
Inspection Report
Census: 29
Capacity: 56
Deficiencies: 1
Date: Jul 30, 2025
Visit Reason
The visit was a case management visit conducted to assess ongoing compliance and follow up on previously identified deficiencies at the facility.
Findings
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.
Deficiencies (1)
Failure to provide personal assistance and care as needed, as three residents refused showers causing malodorous conditions posing an immediate health, safety, or personal rights risk.
Report Facts
Residents refusing showers: 3
Facility wings affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Owen | Administrator | Met with during the inspection and named in relation to findings about resident care and facility conditions. |
| Kayla Adkison | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Lauren Crocker | Licensing Program Manager | Conducted the inspection, provided notes, requested clarification, and signed the report. |
Inspection Report
Census: 30
Capacity: 56
Deficiencies: 0
Date: Jun 30, 2025
Visit Reason
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.
Findings
The report identified concerns including the use of coded locking mechanisms on exit doors restricting resident access, staffing levels and training adequacy, and multiple recent deficiencies cited. The licensee and administrators were directed to develop a compliance plan addressing quality of care, staffing, building oversight, and safety.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Owens | Administrator | Named as Roseleaf Gardens Administrator involved in the compliance meeting. |
| Lauren Crocker | Licensing Program Manager | Named as Licensing Program Manager involved in the compliance meeting. |
| Kayla Adkison | Licensing Program Analyst | Named as Licensing Program Analyst involved in the compliance meeting and recipient of compliance plan. |
| Alycia Rayner | Regional Manager | Named as Regional Manager involved in the compliance meeting. |
| Rajesh Rao | Named as Licensee/Managing Member involved in the compliance meeting. | |
| Sridhar Nagunuri | Named as Licensee/Managing Member involved in the compliance meeting. | |
| Ramaprasad Samudrala | Named as Licensee/Managing Member involved in the compliance meeting. | |
| Stacey Baxter | Administrator | Named as Roseleaf Oroville Administrator involved in the compliance meeting. |
Inspection Report
Census: 30
Capacity: 56
Deficiencies: 0
Date: Jun 30, 2025
Visit Reason
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.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Owens | Administrator | Named as Roseleaf Gardens Administrator present during the meeting and involved in compliance discussions. |
| Lauren Crocker | Licensing Program Manager | Led the discussion of compliance issues and named as Licensing Program Manager. |
| Kayla Adkison | Licensing Program Analyst | Participated in the meeting and responsible for receiving the compliance plan. |
| Alycia Rayner | Regional Manager | Attended the Non-Compliance Conference meeting. |
| Rajesh Rao | Licensee/Managing Member | Attended the meeting as a Licensee/Managing Member. |
| Sridhar Nagunuri | Licensee/Managing Member | Attended the meeting as a Licensee/Managing Member. |
| Ramaprasad Samudrala | Licensee/Managing Member | Attended the meeting as a Licensee/Managing Member. |
| Stacey Baxter | Roseleaf Oroville Administrator | Attended the meeting. |
Inspection Report
Follow-Up
Census: 28
Capacity: 56
Deficiencies: 4
Date: May 27, 2025
Visit Reason
The visit was an unannounced follow-up Case Management - Deficiencies Inspection conducted to ensure the health and safety of residents and verify correction of previous deficiencies.
Findings
The inspection found multiple Type A deficiencies posing immediate health, safety, or personal rights risks, including locked exit doors, accessible cleaning solutions, missing lightbulb and lampshade, and odor issues in multiple rooms. Plans of correction with specific deadlines were required.
Deficiencies (4)
Exit doors were locked with codes rendering them inoperable, posing an immediate health, safety, or personal rights risk.
Cleaning solution was left in a bathroom cabinet accessible to residents, posing an immediate health, safety, or personal rights risk.
One lamp was missing a lightbulb and lampshade, posing an immediate health, safety, or personal rights risk.
Multiple rooms smelled bad, indicating failure to maintain clean, sanitary, and odorless conditions.
Report Facts
Deficiencies cited: 4
Capacity: 56
Census: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Eads | Administrator | Met with inspectors during the visit and was provided the report and appeal rights |
| Lauren Crocker | Licensing Program Manager | Conducted the inspection and cited deficiencies |
| Kayla Adkison | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
Inspection Report
Follow-Up
Census: 28
Capacity: 56
Deficiencies: 4
Date: May 27, 2025
Visit Reason
The visit was an unannounced follow-up Case Management - Deficiencies Inspection to verify correction of previous deficiencies.
Findings
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.
Deficiencies (4)
Exit doors are all locked with codes rendering them inoperable, posing an immediate health, safety or personal rights risk to persons in care.
One cleaning solution was left in a bathroom cabinet accessible to residents, posing an immediate health, safety or personal rights risk.
One lamp was missing a lightbulb and lampshade, posing an immediate health, safety or personal rights risk.
Multiple rooms smelled bad, indicating failure to maintain clean, safe, sanitary, and odorless floor surfaces.
Report Facts
Plan of Correction Due Date: May 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Eads | Administrator | Met with inspection team during visit |
| Kayla Adkison | Licensing Program Analyst | Conducted inspection and signed report |
| Lauren Crocker | Licensing Program Manager | Conducted inspection and named in report |
| Alycia Rayner | Sacramento North Regional Manager | Conducted inspection |
Inspection Report
Annual Inspection
Census: 31
Capacity: 56
Deficiencies: 3
Date: Apr 22, 2025
Visit Reason
The inspection was an unannounced Required-1 Year annual inspection to evaluate the health and safety of residents in care at Roseleaf Gardens facility.
Findings
The facility was generally clean and in good repair with medications properly secured and food stored correctly. However, two resident rooms were odorous, one bathroom was locked and out of order, and some deficiencies related to criminal record clearance, personnel records, and postural supports were identified.
Deficiencies (3)
Failure to comply with criminal record clearance requirements in one out of five staff files, posing an immediate health, safety, or personal rights risk.
Personnel records were not maintained at the facility for one out of five staff files, posing a potential health, safety, or personal rights risk.
Failure to have MD orders on file for use of postural supports (1/2 rails) in two out of five resident rooms, posing a potential health, safety, or personal rights risk.
Report Facts
Deficiencies cited: 3
Hot water temperature: 116
Food supply: 7
Food supply: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stacey Baxter | Administrator | Met during inspection and involved in facility operations. |
| Kayla Adkison | Licensing Program Analyst | Conducted the inspection and signed the report. |
| Lauren Crocker | Licensing Program Manager | Conducted the inspection and signed the report. |
| Kelly Wolfe | Caregiver | Greeted inspectors and toured facility during inspection. |
Inspection Report
Annual Inspection
Census: 31
Capacity: 56
Deficiencies: 3
Date: Apr 22, 2025
Visit Reason
The inspection was an unannounced Required-1 Year annual inspection conducted to ensure compliance with licensing requirements and the health and safety of residents.
Findings
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.
Deficiencies (3)
Failure to comply with criminal record clearance requirements in one out of five files, posing an immediate health, safety, or personal rights risk.
Personnel records were not maintained at the facility for one out of five files, posing a potential health, safety, or personal rights risk.
Failure to comply with postural supports requirements in two out of five rooms, posing a potential health, safety, or personal rights risk.
Report Facts
Capacity: 56
Census: 31
Deficiencies cited: 3
Food supply: 7
Food supply: 2
Hot water temperature: 116
Fire extinguisher service date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stacey Baxter | Administrator | Met during inspection and involved in facility tour |
| Kayla Adkison | Licensing Program Analyst | Conducted the inspection and signed the report |
| Lauren Crocker | Licensing Program Manager | Conducted the inspection and signed the report |
| Kelly Wolfe | Caregiver | Greeted inspectors and participated in facility tour |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 56
Deficiencies: 0
Date: Mar 25, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 56
Census: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diania Bingham | Administrator | Met with Licensing Program Analyst during investigation and signed report |
| Donna Gurriere | Licensing Program Analyst | Conducted complaint investigation and signed report |
| Lauren Crocker | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 56
Deficiencies: 0
Date: Mar 25, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-01-23 regarding allegations of facility staff mismanaging resident supplies, failure to provide a safe environment for residents, and facility disrepair.
Complaint Details
The complaint investigation addressed allegations of mismanagement of resident supplies, unsafe environment for residents, and facility disrepair. After interviews and document review, the findings were unsubstantiated.
Findings
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 to prove the violations occurred.
Report Facts
Capacity: 56
Census: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diania Bingham | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Donna Gurriere | Licensing Program Analyst | Conducted the complaint investigation visit |
| Lauren Crocker | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 56
Deficiencies: 4
Date: Mar 18, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (4)
Facility staff did not seek timely medical attention for resident, delaying emergency services by six days.
Facility staff did not report change in condition to authorized representative in a timely manner.
Facility staff did not meet the needs of residents in care due to insufficient staffing and inability to provide scheduled showers.
Facility was malodorous due to clogged toilets and inadequate maintenance.
Report Facts
Capacity: 56
Census: 31
Residents receiving podiatry services: 10
Civil penalty: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diania Bingham | Administrator | Met with Licensing Program Analyst during investigation and named in findings |
| Donna Gurriere | Licensing Program Analyst | Conducted the complaint investigation |
| Lauren Crocker | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 31
Capacity: 56
Deficiencies: 5
Date: Mar 18, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2025-01-23 regarding allegations of inadequate medical attention, failure to report changes in resident condition, unmet resident needs, and facility malodor.
Complaint Details
The complaint investigation was substantiated. Allegations included failure to seek timely medical attention for a resident, failure to report changes in condition to the authorized representative, unmet resident care needs due to staffing shortages, and facility malodor. The investigation found evidence supporting these allegations.
Findings
The investigation substantiated multiple allegations including failure to seek timely medical attention for a resident, failure to notify the resident's authorized representative of condition changes, inadequate staffing leading to unmet resident care needs, and facility malodor due to clogged toilets. Documentation and interviews supported these findings.
Deficiencies (5)
Failure to meet resident needs as identified in the pre-admission appraisal and provide basic services.
Failure to send resident out for emergency services timely, posing immediate risk.
Failure to observe residents regularly and notify responsible party of changes in condition.
Failure to ensure residents received showers as required.
Failure to maintain facility clean, safe, sanitary, including clogged toilets and odor.
Report Facts
Census: 31
Total Capacity: 56
Residents receiving podiatry services: 10
Civil penalty amount: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diania Bingham | Administrator | Met with Licensing Program Analyst during investigation and named in findings |
| Donna Gurriere | Licensing Program Analyst | Conducted the complaint investigation |
| Lauren Crocker | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 56
Deficiencies: 1
Date: Feb 12, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
87466 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. The facility did not seek any other medical options or communicate with the doctor regarding the resident’s condition which presents an immediate health, safety, and personal rights risk to the residents in care.
Report Facts
Capacity: 56
Census: 34
Plan of Correction Due Date: Feb 13, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Lauren Crocker | Licensing Program Manager | Oversaw the complaint investigation |
| Blatnick | Investigator | Investigated medical records and interviewed staff related to complaint allegations |
| Stacey Baxter | Administrator | Facility administrator who met with the Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 56
Deficiencies: 0
Date: Feb 12, 2025
Visit Reason
The inspection was conducted as a Case Management-Incident Inspection following reports of a resident-to-resident altercation and a resident fall incident.
Complaint Details
The visit was complaint-related due to an incident involving a resident-to-resident altercation and a resident fall. The altercation resulted in no severe injuries and was addressed with physician reassessment and medication changes. The fall report was incomplete regarding outcomes.
Findings
No deficiencies were cited during the inspection. The facility reported no severe injuries from the altercation, and the aggressive resident was reassessed with medication changes. The fall incident report lacked detailed outcome information, and the administrator was educated on proper documentation requirements.
Report Facts
Capacity: 56
Census: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stacey Baxter | Administrator | Met with Licensing Program Analyst during inspection and reported on incidents |
| Farhaan Sarangi | Licensing Program Analyst | Conducted the Case Management-Incident Inspection |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 56
Deficiencies: 1
Date: Feb 12, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 07/08/2024 regarding resident care issues including lack of regular showers, oral hygiene neglect, unexplained broken ribs, delayed medical attention resulting in sepsis, and neglect leading to pressure injuries.
Complaint Details
The complaint investigation was unannounced and addressed multiple allegations including failure to provide regular showers, oral hygiene care, unexplained broken ribs, delayed medical attention for sepsis, and neglect causing pressure injuries. Most allegations were unsubstantiated except for neglect related to pressure injuries which was substantiated.
Findings
The investigation found that most allegations including lack of showers, oral hygiene care, unexplained broken ribs, and delayed medical attention for sepsis were unsubstantiated due to insufficient evidence. However, the allegation of neglect resulting in the development of pressure injuries was substantiated. The facility failed to properly communicate with the resident's physician or seek alternative medical options after home health services were denied, presenting an immediate health and safety risk.
Deficiencies (1)
87466 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.
Report Facts
Capacity: 56
Census: 34
Deficiency count: 1
Plan of Correction Due Date: Feb 13, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Lauren Crocker | Supervisor | Supervisor overseeing the investigation |
| Blatnick | Investigator | Department of Social Services Investigations Branch Investigator who reviewed records and conducted interviews |
| Stacey Baxter | Administrator | Facility Administrator who met with the Licensing Program Analyst during the investigation |
Inspection Report
Census: 34
Capacity: 56
Deficiencies: 0
Date: Feb 12, 2025
Visit Reason
The inspection was conducted as a Case Management-Incident Inspection following reports of a resident-to-resident altercation and a resident fall.
Findings
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.
Report Facts
Capacity: 56
Census: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the Case Management-Incident Inspection |
| Stacey Baxter | Administrator | Met with Licensing Program Analyst during inspection |
| Diania Bingham | Administrator/Director | Named as facility administrator/director |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 56
Deficiencies: 1
Date: Nov 13, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to provide adequate care and supervision as evidenced by lack of documentation of bathing on specified dates with no proof the resident denied showers.
Report Facts
Capacity: 56
Census: 37
Deficiency count: 1
Plan of Correction Due Date: Nov 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Lauren Crocker | Licensing Program Manager | Oversaw the complaint investigation |
| Don Daniels | Resident Services Director | Met with Licensing Program Analyst during inspection |
| Stacy Baxter | Administrator | Interviewed via email regarding bathing documentation and facility care |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 56
Deficiencies: 1
Date: Nov 13, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations received on 2024-08-22 regarding inadequate care and supervision, incident reporting, incontinence care, unexplained injuries, and medical condition changes of a resident.
Complaint Details
The complaint investigation was substantiated for inadequate care and supervision. Other allegations regarding incident reporting, incontinence care, unexplained injuries, and medical condition changes were unsubstantiated due to insufficient evidence.
Findings
The investigation substantiated that staff did not provide adequate care and supervision to a resident, specifically failing to document bathing assistance as required, posing an immediate health and safety risk. Other allegations including improper incident reporting, unmet incontinence needs, unexplained injuries, and failure to address medical condition changes were found unsubstantiated due to insufficient evidence.
Deficiencies (1)
Failure to provide adequate care and supervision as evidenced by undocumented bathing assistance and lack of corroborating evidence that the resident denied showers on specified dates.
Report Facts
Capacity: 56
Census: 37
Plan of Correction Due Date: Nov 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Farhaan Sarangi | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Don Daniels | Resident Services Director | Met with the Licensing Program Analyst during the investigation |
| Stacy Baxter | Administrator | Interviewed via email regarding the complaint findings |
| Lauren Crocker | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 56
Deficiencies: 2
Date: Oct 29, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Personnel Requirements – Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. The licensee did not provide adequate care and supervision by leaving a dementia resident unsupervised outside for an extended period posing immediate health, safety, and personal rights risks.
Care of Persons with Dementia – Licensees must ensure staff providing direct care to residents with dementia receive appropriate training including hydration, skin care, communication, and behavioral challenges. The licensee failed to ensure residents were being hydrated each day.
Report Facts
Civil penalty amount: 1000
Resident Total Body Surface Area burn: 9
Number of staff attempted to interview: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Gurriere | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Lauren Crocker | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Stacey Baxter | Facility representative met with during the investigation. | |
| Diania Bingham | Administrator | Facility administrator named in the report. |
Inspection Report
Complaint Investigation
Census: 34
Capacity: 56
Deficiencies: 2
Date: Oct 29, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit 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.
Complaint Details
The complaint was substantiated. The resident was found to have suffered 3rd degree burns, hypotension, dehydration, hypothermia, and heat stroke after being left unsupervised outside for 30 to 90 minutes in temperatures exceeding 100 degrees. The resident required hospitalization and transfer to a Skilled Nursing Facility and later a medical center for further treatment. The investigation included interviews, record reviews, and medical documentation from multiple sources.
Findings
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 extreme heat. The resident required hospitalization and transfer to higher levels of care. The facility was cited for inadequate staffing and failure to provide adequate care and supervision.
Deficiencies (2)
Personnel Requirements – Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs or the physical arrangements of the facility require such additional staff for the provision of adequate services.
Care of Persons with Dementia – Licensees who accept and retain residents with dementia shall be responsible for ensuring appropriate training including hydration, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living.
Report Facts
Civil penalty amount: 1000
Total Body Surface Area (TBSA) burn: 9
Number of staff attempted to interview: 11
Capacity: 56
Census: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Gurriere | Licensing Program Analyst | Conducted the complaint investigation and delivered final findings. |
| Lauren Crocker | Supervisor | Supervisor overseeing the complaint investigation. |
| Diania Bingham | Administrator | Facility administrator informed of findings and potential penalties. |
| Stacey Baxter | Facility representative met with during the investigation. |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 56
Deficiencies: 1
Date: Aug 6, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Staff did not document when the hospice nurse was contacted to provide the resident with PRN medications.
Report Facts
Capacity: 56
Census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Gurriere | Licensing Program Analyst | Conducted the complaint investigation |
| Lauren Crocker | Licensing Program Manager | Named in report as Licensing Program Manager |
| Diania Bingham | Administrator | Facility Administrator |
| Michelle Long | Administrator Assistant | Met with Licensing Program Analyst during investigation |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 56
Deficiencies: 1
Date: Aug 6, 2024
Visit Reason
A case management visit was conducted to follow up on a complaint investigation received on 2024-05-03 regarding documentation of physician contact when administering PRN medications to a resident.
Complaint Details
The complaint was substantiated based on investigation observations, interviews, and record reviews. The staff failed to document required contacts with the hospice nurse prior to administering PRN medications.
Findings
The investigation found that facility staff failed to document the date and time of contact with the hospice physician and the physician's directions when administering PRN medications to a resident. The allegation was substantiated and a citation was issued.
Deficiencies (1)
Facility staff did not document the date and time of each contact with the physician (hospice) and the physician’s directions when administering PRN medications to a resident.
Report Facts
Capacity: 56
Census: 38
Plan of Correction Due Date: Aug 7, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Gurriere | Licensing Evaluator | Conducted the case management visit and investigation |
| Michelle Long | Administrative Assistant | Met with during the inspection |
| Lauren Crocker | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 56
Deficiencies: 1
Date: Aug 6, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Facility staff did not document the date and time of each contact with the physician (hospice) and the physician’s directions when administering PRN medications to a resident.
Report Facts
Capacity: 56
Census: 38
Plan of Correction Due Date: Aug 7, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Gurriere | Licensing Program Analyst | Conducted the case management visit and investigation |
| Lauren Crocker | Licensing Program Manager | Supervisor and licensing program manager overseeing the inspection |
| Michelle Long | Administrative Assistant | Facility representative met during the inspection |
| Stacy Baxter | Administrator/Director | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 56
Deficiencies: 1
Date: Aug 6, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-05-03 alleging overmedication of a resident, failure to report incidents, insufficient staffing, inadequate administrator presence, and insufficient food/liquid provision to residents.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included overmedication, failure to report incidents, insufficient staffing, inadequate administrator presence, and insufficient food/liquid provision. Interviews and document reviews did not provide sufficient evidence to prove violations.
Findings
The investigation found no preponderance of evidence to substantiate any of the allegations, including overmedication, failure to report incidents, insufficient staffing, inadequate administrator presence, and insufficient food/liquid provision. All findings were determined to be unsubstantiated.
Deficiencies (1)
Staff did not document when the hospice nurse was contacted to provide the resident with PRN medication as required.
Report Facts
Capacity: 56
Census: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diana Bingham | Administrator | Named as facility administrator |
| Michelle Long | Administrator Assistant | Met with Licensing Program Analyst during investigation |
| Donna Gurriere | Licensing Program Analyst | Conducted the complaint investigation |
| Lauren Crocker | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 56
Deficiencies: 2
Date: Jul 10, 2024
Visit Reason
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.
Complaint Details
The visit was complaint-related due to a resident eloping without staff knowledge. Civil penalties were assessed and plans of correction were required.
Findings
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.
Deficiencies (2)
Facility personnel were not sufficient in numbers and competent to provide necessary services, evidenced by leaving a dementia resident unsupervised outside for an extended period posing immediate health, safety, and personal rights risks.
Licensee did not provide an updated medical assessment for a dementia resident, posing potential health, safety, and personal rights risks.
Report Facts
Civil Penalty Amount: 250
Plan of Correction Due Date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jaynae Boyles | Licensing Program Analyst | Conducted the inspection and signed the report |
| Lauren Crocker | Licensing Program Manager | Supervisor named in the report |
| Stacy Baxter | Administrator | Met with during inspection and participated in exit interview |
Inspection Report
Complaint Investigation
Census: 36
Capacity: 56
Deficiencies: 2
Date: Jul 10, 2024
Visit Reason
The inspection was conducted as a Case Management-Incident visit following an incident where a resident eloped from the facility without staff knowledge on June 30, 2024.
Complaint Details
The visit was complaint-related due to an incident where Resident R1 eloped from the facility without staff knowledge on June 30, 2024. The complaint was substantiated by findings of inadequate supervision and lack of updated medical assessment.
Findings
The facility was found deficient for inadequate supervision of a dementia resident who eloped, and for failure to provide an updated medical assessment for a dementia resident. Civil penalties of $250 were assessed.
Deficiencies (2)
Facility personnel were not sufficient in numbers and competent to provide necessary services, evidenced by leaving a dementia resident unsupervised outside for an extended period posing immediate health and safety risks.
Failure to provide an updated annual medical assessment for a dementia resident, posing potential health, safety, and personal rights risks.
Report Facts
Civil Penalty Amount: 250
Plan of Correction Due Date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diania Bingham | Administrator/Director | Facility Administrator named in the report. |
| Stacy Baxter | Administrator | Met with Licensing Program Analysts during the inspection. |
| Jaynae Boyles | Licensing Evaluator | Conducted the inspection and signed the report. |
| Lauren Crocker | Supervisor | Supervisor overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 3
Capacity: 56
Deficiencies: 0
Date: Jul 2, 2024
Visit Reason
The visit was an unannounced case management inspection to discuss an incident that occurred on June 30, 2024.
Complaint Details
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.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Juana Arriaga | Med Tech | Met with during the inspection visit. |
Inspection Report
Complaint Investigation
Census: 3
Capacity: 56
Deficiencies: 0
Date: Jul 2, 2024
Visit Reason
The visit occurred to discuss an incident that happened on June 30, 2024, at the facility. The inspection was unannounced and related to case management of the incident.
Complaint Details
The visit was triggered by an incident report dated June 30, 2024. No findings or substantiation status are provided as the discussion was postponed.
Findings
The licensing evaluators arrived unannounced but were unable to meet with the administrator due to evacuations at a sister facility. The discussion of the incident was postponed to a later date.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Juana Arriaga | Med Tech | Met with during the inspection visit |
| Jaynae Boyles | Licensing Evaluator | Conducted the inspection visit |
| Lauren Crocker | Supervisor | Named as supervisor in the report |
Inspection Report
Complaint Investigation
Census: 33
Capacity: 56
Deficiencies: 1
Date: Apr 25, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff were not assisting residents to change clothes regularly.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to assist resident with dressing as required by medical assessment and care plan from 3/11 to 3/15/2024, four days without assistance.
Report Facts
Capacity: 56
Census: 33
Days without assistance: 4
Plan of Correction Due Date: May 2, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jaynae Boyles | Licensing Program Analyst | Conducted the complaint investigation and made the unannounced visit |
| Lauren Crocker | Licensing Program Manager | Named in relation to the complaint investigation report |
| Don Daniels | Resident Care Coordinator | Met with the Licensing Program Analyst during the investigation |
| Diania Bingham | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 56
Deficiencies: 2
Date: Mar 19, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint received on 2024-01-30 alleging medication errors and inadequate supervision resulting in falls.
Complaint Details
The complaint was substantiated based on interviews, document reviews, and observations. Allegations included failure to provide medication as prescribed, unauthorized alteration of medication, and inadequate supervision leading to falls.
Findings
The investigation substantiated that staff did not provide medication as prescribed, altered a resident's medication without consent, and failed to provide adequate supervision resulting in excessive falls. Deficiencies related to medication orders and fall risk care plans were cited.
Deficiencies (2)
Failed to ensure a prescription order was in place to crush a resident’s medication, posing an immediate health and safety risk.
Failed to comply with Health and Safety code by not having a fall risk care plan in place, posing an immediate health and safety risk.
Report Facts
Capacity: 56
Census: 35
Deficiencies cited: 2
Plan of Correction Due Date: Mar 20, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Gurriere | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Diania Bingham | Administrator | Facility administrator involved in interviews and findings |
| Don Daniels | Facility representative met during the investigation | |
| Lauren Crocker | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 35
Capacity: 56
Deficiencies: 2
Date: Mar 19, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failed to ensure a prescription order was in place to crush a resident’s medication.
Failed to provide care, supervision, and services that meet individual needs, including lack of a fall risk care plan and staff training.
Report Facts
Capacity: 56
Census: 35
Deficiency count: 2
Plan of Correction Due Date: Mar 20, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Gurriere | Licensing Program Analyst | Conducted the complaint investigation and delivered final findings |
| Lauren Crocker | Licensing Program Manager | Named in the report as Licensing Program Manager overseeing the investigation |
| Don Daniels | Facility representative met during the investigation | |
| Diania Bingham | Administrator | Facility administrator involved in interviews and findings |
Inspection Report
Annual Inspection
Census: 36
Capacity: 56
Deficiencies: 7
Date: Mar 5, 2024
Visit Reason
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.
Findings
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.
Deficiencies (7)
Water temperature in two of eight bathrooms was above the required maximum of 120 degrees Fahrenheit without warning signs.
Urine was found in a bucket in a resident's room with dementia, posing a health and safety risk.
One of eight bathtubs observed was not in working order.
Six of six staff files reviewed lacked documentation of TB tests and first aid training.
No fire drills were conducted in the last 12 months.
Two of three resident files with bed rails lacked medical orders for postural supports.
A resident room with oxygen did not have 'No Smoking - Oxygen in Use' signage posted.
Report Facts
Residents' files reviewed: 6
Staff files reviewed: 6
Bathrooms inspected: 8
Rooms with bed rails: 3
Rooms with water temperature above limit: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jaynae Boyles | Licensing Program Analyst | Conducted the inspection and authored the report |
| Lauren Crocker | Licensing Program Manager | Supervisor overseeing the inspection |
| Stacy Baxter | Facility Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Annual Inspection
Census: 36
Capacity: 56
Deficiencies: 8
Date: Mar 5, 2024
Visit Reason
The visit was an unannounced 1-Year Required Annual Inspection conducted to ensure the health and safety of residents in care at Roseleaf Gardens facility.
Findings
The inspection identified multiple deficiencies including unsafe water temperatures in bathrooms, improper disposal of solid waste, missing medical orders for bed rails, lack of staff health screenings and first aid training documentation, a broken bathtub, absence of fire drills in the past year, and missing 'No Smoking - Oxygen in Use' signage outside resident rooms with oxygen.
Deficiencies (8)
Water temperature in two of eight bathrooms was above the required maximum of 120 degrees Fahrenheit.
Urine found in a bucket in a resident's room with dementia, indicating improper solid waste disposal.
Six of six staff files lacked documentation of required health screenings including TB tests.
One of eight bathtubs was not in working order.
Six of six staff files lacked documentation of first aid training.
No fire drills were conducted in the last 12 months.
Two of three residents with bed rails did not have medical orders for postural supports.
A resident room with oxygen did not have a 'No Smoking - Oxygen in Use' sign posted outside.
Report Facts
Residents' files reviewed: 6
Staff files reviewed: 6
Bathrooms inspected: 8
Residents with bed rails: 3
Residents with missing medical orders for bed rails: 2
Fire drills conducted in last 12 months: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jaynae Boyles | Licensing Program Analyst | Conducted the inspection and authored the report |
| Stacy Baxter | Facility Administrator | Met with Licensing Program Analyst during inspection |
| Lauren Crocker | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 56
Deficiencies: 1
Date: Jan 29, 2024
Visit Reason
This unannounced visit was conducted to investigate a complaint alleging that staff were not meeting residents' needs at Roseleaf Gardens facility.
Complaint Details
The complaint alleging that staff were not meeting residents' needs was substantiated based on interviews, record reviews, and evidence. The resident was found outside unsupervised between 11pm and 1am, fell from a wheelchair into a bush with a sprinkler, and staff reported difficulty meeting resident needs. An immediate civil penalty of $500 was assessed.
Findings
The investigation substantiated the allegation that staff did not meet resident needs, specifically that a dementia resident was left unsupervised outside for an extended period, resulting in a fall and injury. The facility was found to have insufficient staffing and inadequate supervision.
Deficiencies (1)
Facility personnel were not sufficient in numbers and competent to provide necessary services, leaving a dementia resident unsupervised outside for an extended period, posing immediate health, safety, and personal rights risks.
Report Facts
Civil penalty amount: 500
Staff scheduled vs. arrived: 2
Staff scheduled vs. total: 3
Capacity: 56
Census: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Don Daniels | Resident Care Coordinator | Met with Licensing Program Analyst during investigation and provided information about the incident |
| Diania Bingham | Administrator | Reported details of the resident incident and staffing on the date of the incident |
| Jaynae Boyles | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Lauren Crocker | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 37
Capacity: 56
Deficiencies: 1
Date: Jan 29, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff were not meeting resident's needs.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. The licensee did not provide adequate care and supervision by leaving a dementia resident unsupervised outside for an extended period, posing an immediate health, safety, and personal rights risk.
Report Facts
Civil penalty amount: 500
Staff scheduled vs arrived: 2
Staff scheduled vs expected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jaynae Boyles | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Don Daniels | Resident Care Coordinator | Interviewed during the investigation |
| Diania Bingham | Administrator | Reported details of the resident incident and staffing |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 56
Deficiencies: 0
Date: Oct 10, 2023
Visit Reason
The inspection visit was conducted to investigate complaints received on 04/21/2023 and 05/01/2023 regarding the facility operating without an administrator and staff providing care without appropriate training.
Complaint Details
Complaint investigation regarding two allegations: 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.
Findings
The allegation that the facility was operating without an administrator was found to be unfounded as the administrator certificate was submitted and accepted effective 04/28/2023. The allegation that staff without appropriate training were providing care was found to be unsubstantiated due to insufficient evidence to prove the violation.
Report Facts
Capacity: 56
Census: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Gurriere | Licensing Program Analyst | Evaluator conducting the complaint investigation |
| Stacey Baxter | Administrator Assistant | Met with evaluator and interviewed during investigation |
| Diania Bingham | Submitted administrator certificate to licensing agency | |
| Lauren Crocker | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 56
Deficiencies: 0
Date: Oct 10, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2023-04-21 alleging inadequate food provision and lack of assistance with self-administration of medication at the facility.
Complaint Details
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. After interviews with staff and review of documentation, both allegations were found unsubstantiated due to insufficient evidence to prove violations.
Findings
The investigation found both allegations to be unsubstantiated. Evidence showed that adequate food was provided with appropriate portions and snacks available, and staff assisted residents with self-administration of medication by ensuring residents took and swallowed their medications.
Report Facts
Capacity: 56
Census: 38
Weight fluctuation: 5
Weight loss: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Gurriere | Licensing Program Analyst | Conducted the complaint investigation |
| Stacey Baxter | Assistant Administrator | Met with the evaluator during the investigation and interviewed regarding allegations |
| Lauren Crocker | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 56
Deficiencies: 0
Date: Oct 10, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 56
Census: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Gurriere | Licensing Program Analyst | Conducted the complaint investigation and delivered final findings |
| Stacey Baxter | Administrator Assistant | Met with the Licensing Program Analyst during the investigation and interviewed regarding allegations |
| Diania Bingham | Submitted administrator certificate to licensing agency | |
| Lauren Crocker | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 56
Deficiencies: 0
Date: Oct 10, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 56
Census: 38
Weight fluctuation: 5
Weight loss: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Gurriere | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Stacey Baxter | Assistant Administrator | Met with Licensing Program Analyst during the investigation and interviewed regarding allegations |
| Lauren Crocker | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Audre Smith | Administrator | Facility Administrator named in the report |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 56
Deficiencies: 0
Date: Jul 18, 2023
Visit Reason
The visit was an unannounced complaint investigation into an allegation that staff did not provide a resident's records to the resident's responsible party.
Complaint Details
The complaint alleged that staff did not provide resident's records to the resident's responsible party. The findings were unsubstantiated.
Findings
The investigation found that although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the alleged violation occurred, and the findings were unsubstantiated.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Gurriere | Licensing Program Analyst | Conducted the complaint investigation and met with facility staff. |
| Stacey Baxter | Administrator Assistant | Met with the evaluator during the investigation. |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 56
Deficiencies: 0
Date: Jul 18, 2023
Visit Reason
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.
Complaint Details
The complaint alleged that staff did not provide resident's records to the resident's responsible party. The findings were unsubstantiated.
Findings
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.
Report Facts
Capacity: 56
Census: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Gurriere | Licensing Program Analyst | Conducted the complaint investigation and met with facility staff |
| Stacey Baxter | Administrator Assistant | Met with Licensing Program Analyst during investigation |
| Diania Bingham | Administrator | Named as facility administrator |
Inspection Report
Complaint Investigation
Capacity: 56
Deficiencies: 3
Date: Apr 11, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (3)
The licensee did not have an adequate financial plan to ensure sufficient resources to meet operating costs for care of residents.
The licensee failed to exercise general supervision over the affairs of their licensed facilities.
The licensee did not maintain liability insurance per the Health and Safety Code requirements.
Report Facts
Capacity: 56
Financial monitoring period: 2
Liability insurance coverage: 1000000
Liability insurance aggregate coverage: 3000000
Plan of Correction Due Date: Apr 17, 2023
Audit documents Due Date: Jul 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Crocker | Licensing Program Manager | Named in relation to the inspection and findings |
| Donna Gurriere | Licensing Program Analyst | Named in relation to the inspection and findings |
Inspection Report
Complaint Investigation
Capacity: 56
Deficiencies: 3
Date: Apr 11, 2023
Visit Reason
The inspection 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 others under the licensee.
Complaint Details
The complaint was received on 07/11/22 regarding financial issues. The investigation found the allegations substantiated based on audit findings and interviews.
Findings
The licensee was found to lack an adequate financial plan, had inadequate liability insurance coverage, and failed to exercise proper general supervision over the licensed facilities. The facility is not in good financial standing due to negative incomes, overdue payments, and negative equity. The complaint was substantiated.
Deficiencies (3)
The licensee does not have an adequate financial plan to ensure residents’ care and supervision won’t be interrupted.
The licensee did not exercise general supervision over the affairs of their licensed facilities.
The licensee did not maintain liability insurance per the Health and Safety Code.
Report Facts
Total Capacity: 56
Financial Monitoring Duration: 2
Liability Insurance Coverage: 1000000
Liability Insurance Aggregate: 3000000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Crocker | Supervisor | Named as supervisor involved in the investigation and report |
| Donna Gurriere | Licensing Evaluator | Named as licensing evaluator conducting the inspection |
Inspection Report
Annual Inspection
Capacity: 56
Deficiencies: 0
Date: Feb 23, 2023
Visit Reason
The visit was an unannounced Required-1 Year Inspection focusing on the infection control domain to ensure compliance with health and safety regulations.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Knight | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Lisa Sapp | Interim Executive Director | Met with the Licensing Program Analyst during the inspection. |
Inspection Report
Annual Inspection
Capacity: 56
Deficiencies: 0
Date: Feb 23, 2023
Visit Reason
The inspection was an unannounced Required-1 Year Inspection focusing on the infection control domain to ensure health and safety compliance at the facility.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Knight | Licensing Program Analyst | Conducted the Required-1 Year Inspection |
| Lisa Sapp | Interim Executive Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Follow-Up
Census: 30
Capacity: 56
Deficiencies: 0
Date: Sep 7, 2022
Visit Reason
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.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Audre Smith | Administrator | Met during the office meeting and discussed staffing levels and facility operations. |
| Sridhar Naguynuri | CEO/Licensee | Met during the office meeting and participated in discussions. |
Inspection Report
Follow-Up
Census: 30
Capacity: 56
Deficiencies: 0
Date: Sep 7, 2022
Visit Reason
The visit was an office meeting held via Microsoft Teams to follow up on a previous meeting held on 07/22/2022, discussing topics related to the facility's operation and compliance.
Findings
The meeting covered topics including the physical plant, staffing levels to meet resident needs, overall operations including consultant roles and staff training, and COVID-19 outbreak status with infection control and visitation guidance. All facilities were cleared through local public health.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Audre Smith | Administrator | Met with licensing staff during the office meeting and discussed staffing levels and facility operations. |
| Sridhar Naguynuri | CEO/Licensee | Met with licensing staff during the office meeting and participated in discussions about facility operations. |
Inspection Report
Capacity: 56
Deficiencies: 0
Date: Jul 22, 2022
Visit Reason
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.
Findings
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.
Report Facts
Capacity: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Audre Smith | Administrator | Facility Administrator present at meeting |
| Sridhar Naguynuri | CEO/Licensee | Facility representative present at meeting |
| Alycia Berryman | Regional Manager | Licensing staff present at meeting |
| Laura Munoz | Licensing Program Manager | Licensing staff present at meeting |
| Jaclyn Avila | Licensing Program Analyst | Licensing staff present at meeting |
| Amber Farmer | Residential Care Coordinator | Representative present at meeting |
| Samantha Guarino | Administrator | Representative present at meeting |
| Stephen Ratliff | Chief Operating Officer | Representative present at meeting |
| Joel S. Goldman | Attorney | Representative present at meeting |
Inspection Report
Capacity: 56
Deficiencies: 0
Date: Jul 22, 2022
Visit Reason
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.
Findings
The report covers discussions on citations issued to Roseleaf Oroville, malfunctioning fire alarm system, inoperable air conditioning and water heater, call system issues, staffing considerations, and administrator vacancies. Several documents were requested for follow-up.
Report Facts
Capacity: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Audre Smith | Administrator | Facility Administrator present at meeting |
| Sridhar Naguynuri | CEO/Licensee | Facility representative present at meeting |
| Alycia Berryman | Regional Manager | Licensing staff present at meeting |
| Laura Munoz | Licensing Program Manager | Licensing staff present at meeting |
| Jaclyn Avila | Licensing Program Analyst | Licensing staff present at meeting |
| Amber Farmer | Residential Care Coordinator | Representative from Roseleaf Oroville present at meeting |
| Samantha Guarino | Administrator | Administrator of Roseleaf Senior Care present at meeting |
| Stephen Ratliff | Chief Operating Officer | Facility representative present at meeting |
| Joel S. Goldman | Attorney | Facility representative present at meeting |
Inspection Report
Census: 30
Capacity: 56
Deficiencies: 0
Date: Apr 27, 2022
Visit Reason
The visit was an unannounced case management visit conducted to tour the facility and discuss relevant forms and protocols.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eric Perry | Executive Director | Met with Licensing Program Analyst and Regional Manager during the case management visit. |
Inspection Report
Census: 30
Capacity: 56
Deficiencies: 0
Date: Apr 27, 2022
Visit Reason
The visit was an unannounced case management visit conducted to tour the facility and discuss the LIC 309 form with the Executive Director.
Findings
No citations were issued during the visit. The Licensing Program Analyst and Regional Manager conducted a tour and confirmed compliance with COVID-19 protocols.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eric Perry | Executive Director | Met with Licensing Program Analyst and Regional Manager during the case management visit. |
Inspection Report
Annual Inspection
Census: 24
Capacity: 56
Deficiencies: 0
Date: Mar 9, 2022
Visit Reason
The inspection was an unannounced Required-1 Year Inspection conducted to evaluate infection control compliance at the facility.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eric Perry | Executive Director | Met with Licensing Program Analyst and Manager during inspection; named in relation to the inspection and exit interview. |
| Jaclyn Avila | Licensing Program Analyst | Conducted the inspection and infection control domain evaluation. |
| Laura Munoz | Licensing Program Manager | Conducted the inspection and infection control domain evaluation. |
Inspection Report
Complaint Investigation
Census: 24
Capacity: 56
Deficiencies: 1
Date: Mar 9, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
87705(f)(2)-Care of Persons with Dementia-The following shall be stored inaccessible to residents with dementia: cleaning supplies and disinfectants. Licensee failed to keep cleaning supplies from 1 of 1 residents in care, posing an immediate health, safety and/or personal rights risk.
Report Facts
Facility capacity: 56
Census: 24
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eric Perry | Administrator | Reported the incident and met with licensing staff during the visit |
| Jaclyn Avila | Licensing Program Analyst | Conducted the inspection and authored the report |
| Laura Munoz | Licensing Program Manager | Conducted the inspection and cited deficiencies |
Inspection Report
Annual Inspection
Census: 24
Capacity: 56
Deficiencies: 0
Date: Mar 9, 2022
Visit Reason
The inspection was a Required - 1 Year unannounced visit to conduct an annual inspection utilizing the infection control domain.
Findings
The facility was found to be in substantial compliance with no immediate health, safety, or personal rights violations observed. No deficiencies were cited as a result of the inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eric Perry | Executive Director | Met with during inspection and named in the report. |
| Jaclyn Avila | Licensing Program Analyst | Conducted the inspection. |
| Laura Munoz | Licensing Program Manager | Conducted the inspection and named as supervisor. |
Inspection Report
Complaint Investigation
Census: 24
Capacity: 56
Deficiencies: 1
Date: Mar 9, 2022
Visit Reason
The visit was an unannounced case management inspection related to a self-reported incident where a resident ingested a 'Mop Pod' due to cleaning supplies being left accessible.
Complaint Details
The complaint investigation was triggered by a self-reported incident on 2/20/2022 where a resident ingested a mop pod. The incident was substantiated by hospital discharge paperwork confirming ingestion of a foreign substance.
Findings
The facility was found to have failed to store cleaning supplies inaccessible to residents with dementia, posing an immediate health and safety risk. The licensee had already taken corrective action by purchasing a new locking cart prior to the visit.
Deficiencies (1)
Failed to store cleaning supplies and disinfectants inaccessible to residents with dementia, specifically a mop pod was accessible to a resident.
Report Facts
Deficiencies cited: 1
Census: 24
Total Capacity: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eric Perry | Administrator | Reported the incident and was present during the inspection |
| Jaclyn Avila | Licensing Program Analyst | Conducted the inspection |
| Laura Munoz | Licensing Program Manager | Conducted the inspection and was the supervisor |
Inspection Report
Census: 26
Capacity: 56
Deficiencies: 0
Date: Feb 16, 2022
Visit Reason
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.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eric Perry | Administrator | Met with Licensing Program Analyst during the visit and received the Order of Immediate Exclusion. |
| Jacob Williams | Licensing Program Analyst | Conducted the case management visit and delivered the Order of Immediate Exclusion. |
| Pauline Willyard | Staff member excluded from the facility by order. |
Inspection Report
Census: 26
Capacity: 56
Deficiencies: 0
Date: Feb 16, 2022
Visit Reason
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.
Findings
The Licensing Program Analyst delivered an exclusion order to the facility administrator regarding staff member Pauline Willyard, who is excluded from the facility for reasons not related to this facility. COVID-19 testing protocols and PPE use were followed during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eric Perry | Administrator | Met with Licensing Program Analyst and received the Order of Immediate Exclusion. |
| Pauline Willyard | Staff member excluded from the facility by order. | |
| Jacob Williams | Licensing Program Analyst | Conducted the case management visit and delivered the exclusion order. |
| Anthony Perez | Supervisor | Supervisor overseeing the licensing evaluation. |
Inspection Report
Census: 25
Capacity: 56
Deficiencies: 0
Date: Aug 1, 2021
Visit Reason
An unannounced site visit and safety check was conducted as part of Case Management - Health Checks at RoseLeaf Gardens facility.
Findings
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.
Report Facts
Staff vaccinated: 11
Residents vaccinated: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dawn Keane | Licensing Program Analyst | Conducted the site visit and document review |
| Eric Perry | Executive Director | Met with Licensing Program Analyst during the visit |
| Melody Manville | Resident Care Coordinator | Provided requested documents and met with Licensing Program Analyst |
Inspection Report
Census: 25
Capacity: 56
Deficiencies: 0
Date: Aug 1, 2021
Visit Reason
An unannounced site visit and safety check was conducted as part of case management and health checks at RoseLeaf Gardens RCFE.
Findings
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.
Report Facts
Staff vaccinated: 11
Residents vaccinated: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dawn Keane | Licensing Program Analyst | Conducted the unannounced site visit and safety check |
| Eric Perry | Executive Director | Met with Licensing Program Analyst during the visit |
| Melody Manville | Resident Care Coordinator | Met with Licensing Program Analyst and provided requested documents |
Inspection Report
Census: 25
Capacity: 56
Deficiencies: 0
Date: Jul 31, 2021
Visit Reason
An unannounced site visit and safety check was conducted at RoseLeaf Gardens to perform case management and health checks, including COVID-19 screening and resident interviews.
Findings
The facility had no deficiencies in care noted during the review of resident files. Most residents reported satisfaction with care and meals, though one resident had not yet received a requested shower. COVID-19 precautions and vaccination rates were documented.
Report Facts
Staff vaccinated: 18
Residents vaccinated: 100
Residents interviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dawn Keane | Licensing Program Analyst | Conducted the site visit and safety check |
| Eric Perry | Executive Director | Met with Licensing Program Analyst during visit |
| Darren Trisel | Administrator | Facility administrator present during visit |
| Tatum McCall | Med Tech | Met with Licensing Program Analyst during visit |
Inspection Report
Census: 25
Capacity: 56
Deficiencies: 0
Date: Jul 31, 2021
Visit Reason
An unannounced site visit and safety check was conducted as part of case management and health checks at RoseLeaf Gardens.
Findings
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.
Report Facts
Staff vaccinated: 18
Residents vaccinated: 100
Residents interviewed: 7
Residents total: 25
Facility capacity: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dawn Keane | Licensing Program Analyst | Conducted the unannounced site visit and safety check |
| Eric Perry | Executive Director | Met with Licensing Program Analyst during visit |
| Darren Trisel | Administrator | Facility Administrator present during visit |
| Tatum McCall | Med Tech | Met with Licensing Program Analyst during visit |
Inspection Report
Original Licensing
Census: 26
Capacity: 56
Deficiencies: 1
Date: Jan 27, 2021
Visit Reason
Pre-licensing inspection conducted via Facetime due to COVID-19 precautions to evaluate the facility for licensure.
Findings
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.
Deficiencies (1)
Facility’s signal system was not in compliance with regulation requiring operation from each resident's living unit and transmission of signals to a central staffed location.
Report Facts
Facility capacity: 56
Current census: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jaclyn Avila | Licensing Program Analyst | Conducted the pre-licensing inspection |
| Eric Perry | Administrator | Met with Licensing Program Analyst during inspection |
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