Inspection Reports for
Roseleaf Oroville

The complaint was substantiated based on interviews and evidence. Staff 1 was found to have handled Resident 1 in a rough manner by spraying Febreze on the resident's genital area.

Staff 1 sprayed Febreze directly onto a resident's genital area, violating the resident's personal rights. The allegation was substantiated and Staff 1 was terminated.

The complaint investigation was substantiated for the allegation that staff left residents in soiled diapers for extended periods due to failure to document incontinent care. Other allegations including untrained medication administration, staff under influence, medication errors, inadequate food service, and failure to respond to call buttons were unsubstantiated.

One allegation that staff left residents in soiled diapers for extended periods was substantiated due to lack of documented incontinent care. All other allegations including untrained medication staff, staff under influence, medication errors, inadequate food service, and failure to respond to call buttons were unsubstantiated.

The complaint was substantiated based on interviews and evidence. Families reported being unable to reach residents by phone, and the facility confirmed phone and cell reception issues in memory care.

The investigation substantiated the complaint that the facility failed to maintain reliable telephone service, preventing families from contacting residents. This posed a potential health, safety, and personal rights risk to residents.

The complaint was substantiated based on the preponderance of evidence standard. The resident was found outside the facility due to a malfunctioning door and inadequate supervision.

The investigation found that a resident eloped from the facility through a malfunctioning keypad door that did not latch properly. Staff failed to provide adequate supervision, posing an immediate health and safety risk. The allegation was substantiated based on evidence and interviews.

The complaint alleging a resident room had a roof leak and sparking electrical outlet was substantiated in part. The roof leak was confirmed, but the sparking electrical outlet was not substantiated.

The investigation substantiated the allegation of a water leak in the ceiling of a resident room, with buckling paint and evidence of a leak on the exterior wall. The allegation of sparking electrical outlets was not substantiated.

The complaint regarding the fire alarm system was found to be substantiated based on the preponderance of evidence standard.

The facility failed to ensure the fire alarm system was in good repair, posing an immediate health and safety risk to residents. The allegation regarding the fire alarm system was substantiated based on evidence and interviews.

The complaint was substantiated based on interviews and evidence obtained during the investigation regarding inadequate heating in the facility.

The facility was found to have temperatures in the lower portion significantly below the required minimum of 68 degrees Fahrenheit, ranging from 61 to 64 degrees, which poses an immediate health, safety, and personal rights risk to residents. The allegation was substantiated and a Type A deficiency was issued.

The complaint investigation was substantiated for the allegation that the facility is in disrepair. The allegation that staff does not ensure resident rooms have sufficient lighting was unsubstantiated.

The allegation of facility disrepair was substantiated with findings of damaged linoleum in the laundry room, non-working ceiling lighting ballasts, and missing cabinet drawers and doors in the food service area. The allegation regarding insufficient lighting in resident rooms was found to be unsubstantiated as all rooms had adjustable ceiling fixtures meeting Title 22 requirements.

The allegation of facility deficiencies was substantiated based on interviews and evidence obtained during the investigation.

A pronounced mildew odor was observed throughout the facility, including the staff restroom and kitchen. A large hole cut in the electrical room floor was found to have been recently wet and was being dried with a construction fan. The licensee was cited for physical plant deficiencies and requested to have repairs made by a licensed contractor.

The complaint investigation was substantiated for the allegation that staff were not properly trained. The allegations that staff did not administer medication as prescribed and that the licensee did not store an adequate amount of food were unsubstantiated.

One allegation that staff were not properly trained was substantiated due to lack of documentation proving required medication training for Staff 1. Two other allegations regarding medication administration errors and inadequate food storage were unsubstantiated based on evidence and interviews.

The complaint investigation was substantiated based on evidence that the kitchen air conditioning was not functioning properly and resident rooms were not kept clean. The licensee was cited for physical plant violations.

The investigation substantiated physical plant violations including a non-functioning kitchen air conditioning system with temperatures reaching 97 degrees F and unclean resident rooms with dirt, dust, and debris under beds and furniture. The facility requires additional housekeeping staff to maintain cleanliness.

The complaint investigation was substantiated for rodent infestation and call system disrepair. The allegation of insufficient staffing was unsubstantiated. The investigation included interviews with staff and pest control, document reviews, and observations. Appeal rights were provided.

The investigation substantiated two allegations: the facility has a persistent rodent infestation despite monthly pest control services, and the call system is in disrepair with several exterior call lights not functioning properly. The allegation regarding insufficient staffing was unsubstantiated.

The facility was generally clean and in good repair with adequate supplies and safety measures. However, deficiencies were found including missing first aid certificates in 2 of 6 staff files and multiple maintenance issues such as a non-draining sink, soiled shower floor, missing light fixture cover, dirty bathroom fan, and discarded items on the premises.

The complaint investigation was substantiated for the allegation that staff did not ensure comfortable facility temperature. The allegation that staff did not maintain the HVAC unit in good repair was unsubstantiated.

The investigation substantiated that staff did not ensure the facility temperature was comfortable, with resident rooms in the lower hall measuring below the required minimum temperature of 68 degrees. The allegation that staff did not maintain the HVAC unit in good repair was unsubstantiated due to insufficient evidence.

The complaint investigation was substantiated for allegations that the facility was in disrepair and not clean. Allegations that staff did not respond to call buttons timely, did not provide clean linen timely, and that the facility had a strong urine odor were unsubstantiated.

Two allegations were substantiated: the facility was in disrepair and staff did not ensure the facility was clean. Three other allegations regarding timely response to call buttons, provision of clean linen, and facility odor were unsubstantiated.

The complaint investigation addressed multiple allegations including inadequate laundry detergent supply, untimely medical attention after a fall, unmet incontinence needs, inappropriate wound care, failure to ensure residents swallow medications, lack of snacks during the night shift, and unclean dishes during the night shift. Only the laundry detergent supply allegation was substantiated; all others were unsubstantiated.

The investigation substantiated that the facility ran out of laundry detergent causing laundry to pile up, posing a potential health and safety risk. All other allegations related to medical attention, incontinence care, wound care, medication administration, availability of snacks, and clean dishes during the night shift were unsubstantiated.

The complaint alleged that staff did not administer a resident's medication, which was substantiated. Other allegations about feeding, wound care, laundry, and temperature were unsubstantiated. The medication omission was a repeat violation with civil penalties assessed.

The investigation substantiated that staff failed to administer a resident's medication (levothyroxine), resulting in hospitalization for severe hypothyroidism. Other allegations related to feeding, wound care, laundry, and temperature were unsubstantiated.

The complaint investigation was substantiated for allegations that staff did not transport a resident safely and failed to bathe a resident as required. Allegations regarding an unexplained injury, improper skin rash care, and failure to provide water were unsubstantiated.

Two allegations were substantiated: staff did not transport a resident safely, resulting in a fall from a wheelchair due to lack of seatbelt use, and staff failed to bathe a resident according to their care plan. Three other allegations regarding unexplained injury, skin rash care, and water provision were unsubstantiated.

The complaint alleged that residents were spoken to in an inappropriate manner, which was substantiated. Another allegation of failure to report medication errors was unsubstantiated after investigation.

The investigation substantiated that a staff member yelled at residents, violating residents' personal rights, resulting in the staff member's termination. Another allegation regarding failure to report medication errors was unsubstantiated as no medication error occurred for one resident and the other was previously substantiated and reported.

The complaint alleged that staff did not give paramedics the resident's emergency paperwork, which was substantiated. Another complaint that staff were not trained properly on emergency procedures was unsubstantiated.

The investigation substantiated that staff did not provide paramedics with the emergency paperwork for a resident, placing the resident at risk due to lack of identifying information. Another allegation that staff were not properly trained on emergency procedures was unsubstantiated.

The complaint alleging the facility was not dispensing medication as prescribed was substantiated based on review of medication administration records and staff interviews. The licensee had a prior deficiency for the same violation within 12 months and was assessed a $250 civil penalty.

The investigation substantiated the allegation that Resident 1 did not receive multiple prescribed medications due to the facility running out of those medications. This posed an immediate health and safety risk and resulted in a civil penalty.

The complaint alleged staff mismanaged medication resulting in a resident being hospitalized. The allegation was substantiated based on interviews, incident reports, and evidence. The resident was hospitalized for observation after receiving another resident's medication. No adverse effects were reported. The facility failed to have a resident photograph for identification, and staff did not follow medication safety protocols.

The investigation substantiated that a medication technician dispensed the wrong medication to a resident, resulting in hospitalization. The resident's admission record lacked a photograph, and the staff failed to follow medication safety checks.

The facility was generally clean and in good repair with adequate supplies and safety measures. However, deficiencies were cited related to expired first aid training certificates for staff and maintenance issues such as broken patio furniture, missing window screens, a refrigerator needing defrosting, and gutters with weeds.

The complaint investigation was substantiated for the allegation that the facility is in disrepair. One allegation was unsubstantiated regarding floors not being kept clean, safe, and sanitary. Two additional allegations required further investigation and are reported separately.

One allegation of facility disrepair was substantiated, including issues with laundry machines, a malfunctioning laundry room door hinge, and leaking shower hoses in resident rooms. Another allegation regarding unsanitary floor conditions was unsubstantiated.

The complaint alleged that the facility toilet was in disrepair. The investigation found no evidence to substantiate the allegation, and the finding was unsubstantiated.

The allegation that the toilet in Room 9 was leaking was investigated and found to be unsubstantiated. The toilet was inspected with no leak or water found, and the reported leak was reportedly fixed prior to the visit.

The complaint investigation was substantiated for the allegation that staff were not ensuring a resident could reach their call button due to a broken call light. All other allegations were found unsubstantiated after review of evidence and interviews.

One allegation regarding staff not ensuring a resident could reach their call button was substantiated due to a broken call light cord. All other allegations including untimely showers, missed meals, failure to seek timely medical assistance, not following special diet orders, residents left in soiled diapers, staff smoking marijuana, and staff taking photographs of residents were unsubstantiated based on interviews, observations, and document reviews.

The complaint investigation was substantiated for failure to notify the authorized representative of a change in the resident’s health condition. Other allegations about resident weight loss, staff neglect, and failure to meet resident needs were unsubstantiated.

The investigation substantiated that staff failed to notify the authorized representative of a resident's change in health condition. Other allegations regarding resident weight loss, staff neglect, and failure to meet resident needs were unsubstantiated.

The complaint was substantiated based on the preponderance of evidence that the resident accessed laundry detergent, leading to hospitalization. The facility was cited under CCR 87705(f)(2).

The investigation substantiated that the resident gained access to laundry detergent stored in the laundry room, posing an immediate health and safety risk. The facility installed a spring hinge on the laundry room door and plans to add cabinet locks to prevent future access.

The complaint investigation was substantiated for failure to properly address an insect infestation. Other allegations including neglect causing a stage 4 pressure injury, failure to assist with feeding and toileting, failure to seek timely medical attention, failure to reposition a resident, inappropriate speech by staff, and leaving a wheelchair-bound resident facing the bed were all unsubstantiated.

The investigation substantiated that the facility failed to properly address an insect and mice infestation, posing an immediate health and safety risk. All other allegations related to resident care including pressure injuries, feeding assistance, toileting, medical attention, repositioning, inappropriate speech, and resident placement were found to be unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was substantiated based on evidence that staff failed to ensure residents were taken to doctor's appointments, unqualified staff provided care, and supplies were insufficient. Other allegations about food service and diapering needs were unsubstantiated.

The investigation substantiated that staff failed to ensure residents received medical attention for infected feet, care was not supervised by qualified professionals, and supplies were insufficient. Other allegations regarding food service adequacy and diapering needs were unsubstantiated.

The complaint was substantiated. The allegation that the facility fire alarm system was in disrepair was confirmed during the investigation.

The investigation substantiated that the facility fire alarm system was malfunctioning and not replaced as recommended, with three egress lighting units not functioning. The facility was cited for a zero tolerance violation and served a civil penalty.

The complaint investigation was substantiated. The allegation that the facility was having financial issues was confirmed based on audit findings and investigation. The licensee is required to submit requested audit documents and is subject to financial monitoring for two quarters or until a sound financial plan is sustained.

The investigation substantiated that the licensee did not have an adequate financial plan to ensure sufficient resources for resident care, failed to maintain required liability insurance, and did not exercise proper general supervision over the licensed facility's affairs. The facility is also in poor financial standing with negative income and equity.

The complaint alleged that staff did not have enough supplies for residents. The allegation was substantiated after investigation.

The investigation found that the facility did not have an appropriate number of incontinence products in various sizes to meet the needs of 32 residents. The allegation was substantiated based on observations, interviews, and record reviews.

The complaint was substantiated based on interviews, observations, and document review. The resident had two Sharps Containers in his room with full syringes and needles needing disposal. The administrator was unaware of one container. The administrator agreed to proper disposal procedures going forward.

The investigation found that the resident had two Sharps Containers in his room, one of which was unknown to the administrator and both were full of syringes and needles needing disposal. The allegation was substantiated and the administrator agreed to house all Sharps Containers in the medication room and take full containers to a collection center for proper disposal.

Two complaints were investigated: one regarding resident hygiene needs and another regarding uncomfortable temperatures inside the facility. The hygiene allegation was unsubstantiated, while the temperature allegation was substantiated based on evidence collected during the investigation.

The allegation that resident hygiene needs were not met was found unsubstantiated due to insufficient evidence. The allegation that facility staff did not maintain a comfortable temperature was substantiated based on temperature measurements and resident complaints, but no new citation was issued due to prior citations on the same issue.

Two allegations were investigated: 1) Facility hallway floors are unclean, which was substantiated. 2) Resident was hospitalized for dehydration, which was unsubstantiated. The investigation included interviews with the administrator and staff, review of documents, and on-site observations.

The allegation that facility hallway floors were unclean was substantiated based on observations of large stains on carpeted floors and liquid on laminate floors. The allegation that a resident was hospitalized for dehydration was unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was substantiated for laundry equipment disrepair, lack of laundry services, and window screen maintenance issues. Allegations about staff speaking inappropriately and hallway lighting were unsubstantiated. Allegations about trip hazards and PPE provision during an outbreak were unfounded.

The investigation substantiated that the facility's laundry equipment was in disrepair and laundry services were not properly maintained, and window screens required repairs. Other allegations regarding staff speaking inappropriately, hallway lighting, trip hazards, and PPE availability were found to be unsubstantiated or unfounded.

The complaint investigation was substantiated for allegations of staff negligence and medication errors leading to hospitalization. Another complaint about failure to provide documentation to the POA within two business days and failure to contact doctor or palliative care was unsubstantiated.

The investigation substantiated that a resident was given the wrong medication and sent to the hospital as a precaution, where the resident was diagnosed with a urinary tract infection and dehydration that staff did not observe. Another complaint regarding failure to provide documentation to the POA within two business days and failure to contact doctor or palliative care was unsubstantiated.

The visit was triggered by a complaint regarding a resident who went AWOL on 2022-09-10. The complaint was substantiated as the resident left the facility undetected due to an open perimeter gate and insufficient staff supervision.

The facility failed to provide adequate direct care staff to support residents with dementia, resulting in a resident eloping undetected for approximately 45 minutes. Additionally, multiple sinks in the kitchen were leaking, causing water damage and mold, posing immediate health and safety risks. Observations also noted residents with injuries from unwitnessed falls and insufficient supervision.

The complaint investigation was substantiated. Allegations included multiple falls by a resident, delayed medical attention by staff, and misplaced resident belongings. Evidence from interviews, incident reports, and documentation supported these findings.

The investigation substantiated all allegations based on interviews, observations, and record reviews. It was confirmed that a resident sustained multiple falls requiring assistance, staff delayed medical attention after a fall causing a skin tear, and the resident's belongings were misplaced upon discharge.

The complaint investigation was substantiated. Allegations included failure to follow medical orders, failure to seek timely medical attention, and inaccurate medication dosage. The resident was ill with black vomit and diarrhea, staff did not call 911, and the resident later collapsed and died. Medication dosage error involved a resident receiving 1 tablet instead of the prescribed 1.5 tablets of Losartan Potassium. Civil penalties were assessed.

The investigation substantiated that staff failed to notify the medical professional of a resident's health decline, did not call 911 during a medical emergency, and administered an incorrect medication dosage. Civil penalties of $500 were assessed for a resident sustaining serious bodily injury while in care.

The complaint investigation was substantiated based on observations and interviews. Staff were observed wearing masks improperly and not screened at the front door. The water heater valve needed replacement, causing residents to be showered in alternate locations, leading to some refusals.

The investigation substantiated the allegations, finding staff not consistently following masking requirements and a malfunctioning water heater that prevented residents from controlling water temperature, posing a health and safety risk.

The complaint investigation was substantiated. The facility was found to have temperatures in resident rooms and common areas exceeding the comfortable range, and residents were denied visitation rights since 6/24/2022. The findings were based on observations, interviews, and temperature measurements taken during the visit.

The investigation substantiated the complaints, finding that the facility temperature was excessively high in multiple areas and that residents were not allowed visitors since 6/24/2022, with visitation only permitted through windows. These conditions posed immediate health, safety, and personal rights risks to residents.

The complaint investigation was substantiated. Allegations included a resident eloping through a faulty gate, disrepair of the air conditioning, water system, fire alarm system, and gate. The facility failed to provide incident reports and had ongoing maintenance issues. The fire alarm system was recommended for replacement by the Deputy Fire Marshal.

The investigation substantiated the allegations that a resident eloped through a gate in disrepair, the air conditioning unit and water system were broken and unrepaired for about a month, the fire alarm system was malfunctioning and recommended for replacement, and the gate was secured by a cable and lock after the elopement but remained unrepaired since May 2022.

The complaint alleging staff were not appropriately wearing masks was substantiated based on observations and interviews. The facility was found not to be following its mitigation plan submitted to Licensing.

The investigation substantiated that facility staff were not wearing masks appropriately, violating the submitted mitigation plan. Staff were observed wearing masks under their noses and chins, and the facility admitted to needing constant reminders about mask usage.

The complaint investigation was substantiated for lack of supervision resulting in a resident sustaining burns and facility staff not following the resident's care plan. The resident required hospitalization, surgery, and rehabilitation for third-degree burns. A civil penalty was issued for serious bodily injury.

The investigation found that the facility failed to provide appropriate supervision to the resident while smoking, resulting in the resident catching fire and sustaining serious burns requiring hospitalization, surgery, and rehabilitation. A civil penalty of $10,000 was issued for serious bodily injury due to inadequate care and supervision.