complaint·July 15, 2022

This Department has investigated the above listed allegations and found them to be substantiated. This Department has conducted interviews and made observations during a tour of the facility on 7/15/2022. Allegation: A Resident (R1) eloped from the facility. This Department conducted staff interviews which revealed R1 was located outside of the facility by a different resident’s family. Although R1 was not witnessed leaving the building, staff interviewed believed it was through a gate in which the egress was not working. The mechanism in the gate needed to be repaired and the gate door would swing open. The facility placed pots and chairs to prevent the gate from opening. After the elopement, the facility utilized a cable to lock the gate. This Department requested a copy of the incident report. Staff present during the site visit on 7/15/2022 where unable to provide a copy. This Department contacted the administrator who stated she thought she sent the unusual incident report regarding the elopement of R1 however the facilities internet has been working off and on. No staff were able to provide the date of occurrence, but all confirmed it happened during interview. This department reviewed R1’s physicians report dated 3/30/2022 which is marked that R1 can not leave the facility unassisted. Allegation: Facility A/C is in disrepair- This Department conducted interviews with facility staff to include administrator. The investigation revealed that the A/C has been broken for approximately a month. The facility has reached out to their vendor and were told the unit needed to be replaced. To date the air conditioning unit has not been fixed nor replaced. Allegation: Facility water system is in disrepair. The investigation revealed that a valve on the water heater needs to be replaced and residents nor staff can control the temperature of the water. Due to this, residents affected have not been showering in their own shower but are taken to a different location in the building to shower which has resulted in some refusals of residents to shower. The water system has been in disrepair for approximately a month and has not been fixed to date. Allegation: Fire alarm system is in disrepair. In June of 2022, Roseleaf Oroville experienced the fire alarm system malfunctioning at which time they reached out to the vendor who inspected the system. The vendor recommended the system be replaced due to the system being antiquated and provided the invoice to the administrator who provided it to the Chief Operating Officer for the licensee. To date the system has not been replaced as recommended. Deputy Fire Marshal joined this department in a tour of the facility and strongly recommended the fire alarm system be replaced. Three egress lighting units did not function during the inspection on 7/15/2022 at 3:50 PM. These lights are instrumental in the event there is a power outage. Allegation: Gate is in disrepair. During a tour of the facility this Department observed that the gate is being secured by a cable and lock. This cable and lock were not implemented until an elopement of a resident occurred. The mechanism securing the gate has been in disrepair since May 2022 and has not been fixed to date. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. The following deficiencies were cited per Title 22 of the California Code of Regulation (See LIC 9099D ). Appeal Rights were explained and provided to the facility representative listed above and an Exit Interview was conducted. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.