Roseleaf Oroville

Based on observation the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.LPA observed the following during the inspection: A broken plexiglass window in the medication room (currently not in use) located in the lower portion of the facility next to the common area. This plexiglass needs to be replaced.Discarded wheelchairs, mattresses, beds etc. located in the sunroom in memory care unit. These items need to be removed.Broken/discarded bed located on the porch on the south side of the facility in the garden area. This needs to be removed.Discarded chairs located in the exterior alcove located on the exterior of the upper memory care medication room. These need to be removed.One window screen was on the ground on the exterior east side of the facility in the garden area. This screen needs to be re-installed.Portion of sidewalk located in the rear garden next to the back fence had puddles of water from the drip irrigation system. This system needs to be inspected and repaired to prevent pooling of water.Discarded commode, walker, and wheelchair in the shaded exterior activities area. These items need to be removed.

87468.1 (a)(3) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature. This requirement is not met as evidenced by: Based on interviews it was determined that Staff 1 (S1) sprayed R1 with Febreze which violates R1’s personal rights. This poses an immediate health and safety risk to residents in care.

87411(a) Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. This requirement was not met as evidenced by: Based on records review staff did not record toileting care for 2 residents, which poses a potential health, safety, or personal rights risk to residents in care.

87311 Telephones - All facilities shall have telephone service on the premises. This requirement was not met as evidenced by: Based on interviews the licensee failed to ensure that the facility had reliable and correctly functioning telephone service which prevented families from being able to contact residents. This poses a potential health, safety, and personal rights risk to residents in care.

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: LPA observed that the interior door with key pad entrance was malfunctioning. When staff entered the code the door opened and dis-alarmed. When staff let go of the door LPA observed that the door did not automatically close though the keypad read that the door was secured. This is likely how R1 was able to enter the facility lobby through the unlatched door.This poses an immediate health and safety risk to residents in care.

87411(a) Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Based on interviews and document review the facility failed to ensure that 1 of 24 residents was not able elope from the facility out into the street at night where they were found in their wheelchair in a parking lot ditch. This poses an immediate health and safety risk to residents in care.

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: LPA inspected Room 2 and found that there was a water leak in the ceiling on the north-west corner. LPA witnessed buckling paint on the interior wall. LPA viewed the exterior wall of the room (which is in a corner of the building and determined that a leak was present in the corner. This poses an immediate health and safety risk to residents in care.

87213 Finances The licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that assures sufficient resources to meet operating costs for care of residents; shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency. Such request shall explain the need for disclosure. The licensing agency reserves the right to reject any financial report and to request additional information or examination including interim financial statements. This requirement has not been met as evidenced by: Based on LPA record review the facility did not pay their PGE bill which resulted in PGE serving a FINAL NOTICE BEFORE DISCONNECTION. The facility currently has a past due amount of $4,481.00 that is due by 12/23/2025. LPA reviewed past due invoices from multiple vendors who have not been paid by the licensee. This poses an immediate health, safety, and personal rights risk to residents in care.

87303(b) Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times.(1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C).This requirement was not met as evidenced by: Based on observation the facility failed to ensure that common areas and resident rooms are at a comfortable temperature which poses an immediate health, safety and personal rights risk to residents in care.

87303(a) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: Based on observation and record review the facility failed to ensure that the fire alarm system was in good repair which poses an immediate health, and safety risk to residents in care.

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: LPA observed the linolem in the laundry room is damaged / worn, two ceiling lighting ballasts in the laundry room that were not in working order, upper floor food service area observed that four cabinet drawers were missing and one cabinet door is missing.

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: LPA observed a pronounced mildew smell in the facility and observed a large hole had been cut into the floor of the electrical room of the facility which poses a potential health, safety or personal rights risk to persons n care.

87411 (c)(6) Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. (6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer. This requirement was not met as evidenced by: Based on LPA record review the licensee failed to document that Staff 1 (S1) had completed training before being allowed to dispense medications which poses a potential health and safety risk to residents in care.

87303(a) Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: LPA obserevd the kitchen temperatre to be 97 degrees F at 11:10 AM. LPA found a large amount of dirt, dust, and debris under resident beds, under night stands and in corners of the rooms. The rooms were generally untidy and unclean. This poses a potential health and safety risk to resident in care and staff working in the facility.

87303(a) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on observation, document review and interviews it was determined that although the facility has monthly pest control services the issue with rodents still persists. This poses a potential Health, Safety and Personal Rights risk to residents in care.

87303(1)(i)(c) Maintenance and operation (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more … shall have a signal system which shall: (C) Identify the specific resident living unit. This requirement was not met as evidenced by: Based on observation it was determined that six rooms in the lower hallway have exterior call lights that either do not light or are very dim when the call button is pushed in the resident room. This poses a potential Health, Safety and Personal Rights risk to clients in care.

Based on records review, the licensee did not comply with the section cited above in 2 of 6 staff files which did not contain First aid certificates.which poses a potential health, safety or personal rights risk to persons in care.

Based on observation the licensee did not comply with the section cited above in Lower activities room common bathroom sink not draining. Room 9 shower floor soiled. Room 26 bathroom light fixture missing glass cover. Room 26 bathroom fan dirty. Discarded items need to be removed from west side entrance to include motorized wheelchair and mattress. Sun room currently has discarded rental equipment (beds, oxygen cannisters, wheelchairs, walkers) that need to be picked up by rental company. Two window screens need to be re-installed on exterior windows on South side of the building. Weeds need to be removed from gutters overs entrance to activity room. Discarded metal table needs to be removed from backyard. Discarded heavy metal doors need to be removed from east side activity area.which poses a potential health, safety or personal rights risk to persons in care.

87303(b)(1) Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. (1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C). Based on LPA observation resident rooms in the lower hall measured 62 degrees in four resident rooms, this is below the required minimum temperature reading of 68 degrees.

87303(g)(1) Maintenance and Operation (g) Facilities which have machines and do their own laundry shall: (1) Have adequate supplies available and equipment maintained in good repair. This requirement was not met as evidenced by: Based on interviews and document review it was determined that the facility ran out of laundry detergent causing the laundry to pile up. This poses a potential health and safety risk to residents in care.

87303(a) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on LPA observation it was determined that the shower floor for 1 resident was very dirty. In the upper dining room LPA observed significant dirt and grime on the floor next to the double doors. In the upper dining room the section of wall under the breakfast bar had been patched but needed to be painted. In the decline to the left of the hallway the section of wall was missing the baseboard and this wall needed to be painted. In this decline hallway the linoleum baseboards needed to be cleaned. The baseboard outside of water heater closet was missing and the wall needs to be painted in addition hallway wall needs to be painted. This poses a potential health and safety risk to residents in care.

87465(a)(4) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews and document review it was determined that due to R1 not receiving his levothyroxine medication, his hyperthyroidism was untreated, and R1 was hospitalized and treated for severe hypothyroidism. This poses an immediate health and safety risk to residents in care.

87468.2 (a)(4) Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are competent to meet their needs. This requirement was not met as evidenced by: Based on interviews and document review it was determined that staff did not ensure that a seatbelt was placed on R1 prior to transport in the facility van which resulted in R1 falling out of their wheelchair. This poses a potential health and safety risk to residents in care.

Health and Safety Code section 1569.2(c) provides: (c) "Care and supervision" means the facility assumes responsibility for, or provides… ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This requirement was not met as evidenced by: Based on interviews and document review it was determined that staff did not ensure that Resident 1 is provided assistance in showering with the required number of showers as required in their care plan. This poses a potential health and safety risk to residents in care.

87465(a)(4) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews and document review it was determined that R1 ran out of multiple medications for a period ranging from 8 to 18 days. This poses an immediate health and safety risk to residents in care.

87506(a) Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff. This requirement was not met as evidenced by: Based on interviews and document review it was determined that the paper file for R1 was not on file and the facility had not entered the resident’s record into their database where it could be accessed by facility staff. This resulted in staff not being able to provide EMS with the identifying records that are required by EMS in order to transport a resident to hospital. This poses a potential health and safety risk to residents in care.

87468.1 (a)(1) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff. This requirement was not met as evidenced by: Based on interviews it was determined that S4 yelled at residents. This poses a potential health and safety risk to residents in care.

Based on record review, the licensee did not comply with the section cited above in 4 of 6 staff files which pose a potential health, safety or personal rights risk to persons in care.

Based on observation the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.

87465(a)(4) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews and document review it was determined that a med tech dispensed the wrong medication to 1 resident resulting in hospitalization. This poses an immediate health and safety risk to residents in care.

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on LPA observation and interviews it was determind that 1 washing machine is inoperational, 3 shower hoses need to be replaced in resident rooms, latch in laundry room door is malfunctioning. This poses a potential health and saftey risk to residents in care.

87303(A) Maintenance and Operation - Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more … shall have a signal system which shall: (A) Operate from each resident's living unit. This requirement is not met as evidenced by: Based on LPA interviews and observation it was determined that the call light in 1 resident room is missing the pull cord causing R1 to not be able to activate their call light unless they are in their bed against the wall which poses a potential health and safety risk to residents in care.

Personal Rights - To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met as evidenced by: Based on interviews and document review, the licensee did not ensure that the resident’s authorized representatives were regularly informed of the resident’s change of condition.

87705(f)(2) Care of Persons with Dementia - (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on interviews, it was determined that Resident 1 gained access to a laundry room and was found by staff with a cup of laundry detergent in their hand and laundry detergent around their mouth. This poses an immediate health and safety risk to residents in care.

Healing Wounds: the licensee shall be permitted to accept or retain a resident who has a healing wound under the following circumstances: When care is performed by or under the supervision of an appropriately skilled professional. This requirement was not met as evidenced by: Based on interviews and records reviewed, the licensee did not ensure that care for the resident was under the supervision of an appropriately skilled professional. This poses an immediate health, safety, and personal rights risk to residents in care.

Basic Services: A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs… This requirement was not met as evidenced by: Based on interviews and records reviewed, the licensee did not ensure that the resident received medical attention for his feet and toes. This poses an immediate health, safety, and personal rights risk to residents in care.

Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on documentation and interviews, the licensee did not ensure that the facility was clean, safe and sanitary. This poses an immediate health and safety risk to residents in care.

Fire Safety - All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. The licensee did not ensure that the Facility Fire Alarm System was in working condition. This is a zero tolerance violation and the facility shall be served a civil penalty this date.

Finances - The licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that assures sufficient resources to meet operating costs for care of residents; shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency… The licensee did not ensure that there were sufficient resources to meet operating costs for the care of residents.

Accountability of Licensee Governing Body - The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves.If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability. The licensees did not exercise general supervision over the affairs of their licensed facilities.

Liability Insurance - On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. The licensee did not maintain liability insurance per the Health and Safety Code.

Managed Incontinence - The licensee shall be permitted to accept or retain a resident who has a manageable bowel and/or bladder incontinence condition under the following circumstances:... The licensee did not have the appropriate number of incontinence products available to ensure that the residents remain changed and dry.

Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. The licensee did not ensure that the resident’s room was safe, as there were needles and syringes in a Sharps Container, that were not disposed of.

Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times…The licensee did not ensure that this requirement was met as evidenced by observations. Large stains were noted on the carpeted floors and liquid was observed on the laminate floors.

Basic services requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services:Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. Licensee failed this by a resident being sento the hospital and being diagnosed with a urinary tract infection and dehydration that the staff did not observe. This is an immedate health and safety risk to residents

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This is evidenced by: Licensee failed this by: not having a plan for when the laundry machines stop working and the dirty laundry not being done. The window screens requiring repairs not being done timely. This is a potential risk to the health and safety of the resident.

Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed. This is evidenced by: Licensee failed this by a resident being given the wrong medication and as a result the resident was sent to the hospital. This is an immediate risk to the health and safety of the resident.

87705(c)(4) Care of Persons with Dementia-Licensees who accept and retain residents with dementia shall be responsible for ensuring: There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs.This requirement is not met as evidenced by: Based upon observation and interview the Licensee failed to provide enough care staff to ensure the safety and health care needs of 1 of 1 residents who had a history of AWOL.This poses an immediate Health, Safety and/or Personal Rights risk to residents in care.

87555 General Food Service Requirements(b) The following food service requirements shall apply:(29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips.This requirement is not met as evidenced by: Based upon observation and interview the Licensee failed to keep 4 of 4 sinks in the kitchen from leaking and creating water damage and mold.This poses an immediate Health, Safety and/or Personal Rights risk to residents in care.

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.

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.

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.

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.

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.

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.

87303(a) Maintenance and Operation-The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement is not met as evidenced by: Based upon observation and interview the Licensee failed to keep the gate, air conditioning unit and water heater in good repair.This poses an immediate Health, Safety and/or Personal Rights risk to residents in care.

87705(c)(4) Care of Persons with Dementia-Licensees who accept and retain residents with dementia shall be responsible for ensuring: There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs.This requirement is not met as evidenced by: Based upon observation and interview the Licensee failed to provide enough care staff to ensure the safety and health care needs of 1 of 1 residents.This poses an immediate Health, Safety and/or Personal Rights risk to residents in care.

87464 Basic Services - (f) Basic services shall at a minimum include:(2) Safe and healthful living accommodations and services.This requirement is not met as evidenced by: Based upon observation and interview the Licensee failed to maintain the water heater which has resulted in the inability to adjust the temperature in residents own showers or sinks.This poses an immediate Health, Safety and/or Personal Rights risk to residents in care.

87303 Maintenance and Operation(b) A comfortable temperature for residents shall be maintained at all times.(2) The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. This requirement is not met as evidenced by: Based upon observation and interview the Licensee failed to provide a comfortable temperature to residents,This poses an immediate Health, Safety and/or Personal Rights risk to residents in care.

87468.1 Personal Rights of Residents in All Facilities -(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice This requirement is not met as evidenced by: Based upon observation and interview the Licensee failed to allow 36 of 36 residents in care their right to visitors.This poses an immediate Health, Safety and/or Personal Rights risk to residents in care.

87470(c)(1)(F) Infection Control Requirements: An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. The Infection Control Plan shall include all of the following: Staff shall demonstrate knowledge of and skill in infection control... This requirement has not been met as evidenced by: LPA's interviews and observations. Staff did not follow infection control requirements as required. This poses an immediate risk to the health and safety of residents in care.