Inspection Report Summary
Most inspections found deficiencies related to resident care, supervision, and safety, with several substantiated complaints involving inadequate staffing, delayed medical attention, and failure to meet residents’ needs. The facility was cited multiple times for leaving dementia residents unsupervised, resulting in injuries and hospitalization, and was assessed civil penalties including a $1,000 fine in October 2024 and a $250 fine in July 2024. Other common issues included malodorous conditions due to insufficient personal care, locked exit doors restricting resident access, and documentation lapses. Several complaint investigations were unsubstantiated, particularly those alleging overmedication, inadequate food, and improper staffing. The most recent report from July 30, 2025, cited a deficiency for failure to provide personal assistance related to resident hygiene, indicating ongoing challenges in resident care despite some corrective plans.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
7.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
80% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
52% occupied
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
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 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 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 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: 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: 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
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: 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: 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
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: 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: 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: 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 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
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 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 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
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
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
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
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
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
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: 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: 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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