Inspection visit

complaintAugust 9, 2022

Clean visit · 0 citations

Inspector’s narrative

What the inspector wrote

Resident 1 was attacked by Resident 2 . During the investigative process, the assistant administrator, six staff persons and other persons were interviewed. Various documents were obtained and reviewed to include Physicians Report, Admission Agreement, Incident Reports, Activities of Daily Living Basic Care Services, Appraisal/Needs and Services Plan, and the Resident’s Assessment document. During the interview process, overall, staff persons reported that they were not aware of an incident where Resident 1 was attacked by Resident 2. It was reported that Resident 2 “threatened” staff with a fork and knife; however, no physical contact was made. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated . Residents' are left in incontinence products . During the investigative process, the assistant administrator, six staff persons and other persons were interviewed. Various documents were obtained and reviewed to include Physicians Report, Admission Agreement, Incident Reports, Activities of Daily Living Basic Care Services, Appraisal/Needs and Services Plan, and the Resident’s Assessment document. During the interview process, most staff persons reported that residents are checked for soiled incontinence products every two hours and that staff follow a schedule for checking on the residents. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated . continued A resident (Resident 2) entered another resident’s room (Resident 1) undressed. During the investigative process, the assistant administrator, six staff persons and other persons were interviewed. Various documents were obtained and reviewed to include Physicians Report, Admission Agreement, Incident Reports, Activities of Daily Living Basic Care Services, Appraisal/Needs and Services Plan, and the Resident’s Assessment document. During the interview process, staff persons reported that they did not witness resident 2 enter into resident 1’s room undressed. It was reported that resident 2 at times would undress, but he was not observed undressed in resident 1’s room. Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated.

Citations

6 citations recorded^*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

87217(b)Type B
Safeguards for Resident Cash, Personal Property, and Valuables - Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee did not ensure that this requirement was met as evidenced by interviews and record reviews in that when the resident left the facility, she did not receive all of her belongings. This poses a potential risk to resident’s in care.
87464(f)(1)Type A
Basic Services - Basic services shall at a minimum include: Regular observation of the resident's physical and mental condition, as specified in Section 87466, Observation of the Resident. The licensee did not ensure that this requirement was met as evidenced by interviews and records review in that it was documented in several places that the resident needed assistance and supervision when walking. This poses an immediate risk to residents in care.
87465(a)(1)Type A
Incidental Medical and Dental Care - The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. The licensee did not ensure that this requirement was met as evidenced by interviews and record reviews in that a staff person working the nighttime shift did not contact Emergency Services (911) when a resident fell and sustained a large skin tear on her arm. This poses an immediate risk to residents in care.
87465(a)(5)Type A
Incidental Medical and Dental Care - Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. The licensee did not ensure that this requirement was met as evidenced by documentation that reflects an order change; however, was not followed. This poses an immediate risk to residents.
87465(g)Type A
Incidental Medical and Dental Care - The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). The licensee did not ensure that staff persons called 911 during an incident that caused an imminent threat to the resident’s health. This poses an immediate Health and Safety risk to residents.
87466Type A
Observation of a resident - 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. The licensee did not ensure that a resident’s medical professional was notified of a resident’s health change.This poses an immediate Health and Safety risk to residents.

FAQ · About this visit

Common questions about this visit

What happened during the August 9, 2022 inspection of ROSELEAF OROVILLE?

This was a complaint inspection of ROSELEAF OROVILLE on August 9, 2022. The inspection found no deficiencies and no citations were issued.

Were any citations issued to ROSELEAF OROVILLE on August 9, 2022?

No citations were issued during this inspection. The facility was found to be in compliance with all applicable regulations.

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLD View original report

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Data from CCLD public records. Last updated May 25, 2026. If you believe any information is inaccurate, report it here.

complaint·August 9, 2022