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Inspection visit

complaint

ROSELEAF GARDENSLicense 0450027751 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

Allegation Facility failed to meet a residents needs in a timely manner . It was alleged that on October 8, 2025, staff were assisting a Resident (R1) with transferring to the restroom. After assisting R1 with sitting down, staff allowed R1 privacy and informed R1 "they would return in a few minutes." It was alleged that no staff returned to assist R1 for approximately 1.5 hours. R1 reported they verbally called for assistance, however, no staff returned. R1 attempted to get up themselves resulting in a fall where they hit their head. R1 reported they were on the floor for approximately 15 more minutes before staff arrived to help. R1 reported they did not use the bathroom's pull cord for assistance as "we were told they didn't work. " (See complaint investigation #59-AS-20251021112112). R1 indicated they knew the length of time they were left unattended because they were wearing a watch. R1 stated they were left in the bathroom at approximately 7:30 pm and by 9:00 pm nobody had returned. LPA reviewed R1's care notes for March 8, 2025. Care staff noted at 9:50 PM, "Resident attempted to get off the toilet without assistance and landed on butt on the floor. No injury and staff assisted him up. No further concern. MD notified." R1 indicated staff asked if R1 was alright after the fall and then assisted R1 to their bed. Emergency Medical Services (EMS) were not contacted to evaluate R1 for injuries. On March 9, 2025, care notes indicated R1's family member had informed staff of a red bump on R1's head. R1 stated it was from where they had hit their head the night before. LPA reviewed R1's LIC 602 (Medical Assessment) dated August 21, 2025, which indicated R1 had no cognitive conditions and was unable to care for their own toileting needs. LPA reviewed R1's care plan dated July 1, 2025, which indicated "Staff to provide hands-on assistance for bladder or bowel incontinence management." LPA attempted to interview staff members who were present at the time of the incident, but received no return phone calls. Additionally, staff who recorded the care notes documenting the incident are no longer employed at the facility. Based on observations, interviews, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099-D. Exit interview conducted. A copy of this report and Appeal Rights were provided to Administrator, Bailey Malagon.

Citations

5 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.

  • 87411(a)Type A

    87411 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 violation is evidenced by: Based on interview and record review, the licensee failed to meet the residents needs in that they did not follow the resident's care plan to provide hands on toileting asisitance and they left the resident unattended for approximately 1.5 hours, resulting in R1 sustaining a fall and injury, which poses a potential health, safety, or personal rights risk to resident's in care.

  • 87211(a)(1)(D)Type B

    87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below (D) Any incident which threatens the welfare, safety or health of any resident.This is evidenced by: Based on Observation, Interview, and Record Review, the licensee/administrator failed to report an incident in which R1's welfare was threatened, which poses a potential health, safety, or personal rights risk to persons in care

  • 87465(g)Type B

    87465 Incidental Medical and Dental Care (g) 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...This is evidenced by: Based on observation, interview, and record review, the licensee failed to seek medical assistance for the resdient after a fall and sustained injury,

  • 87468.1(a)(2)Type B

    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:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This is evidenced by: Based on observation, interview, and record review, the licensee failed to provide safe accomodations for the resident in that staff did not follow the resident's care plan to have only bed baths resulting in a fall while in the care of staff, which poses a potential health, safety, or personal rights risk to persons in care

  • 87625(b)(3)Type B

    87625 Managed Incontinence (b) In addition to Section 87611... the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.This is evidenced by: Based on observation, record review, and interviews, the licensee did not ensure that incontinence needs of residents were being met in that resdients were found soaked through their bedding at shift changes on more than one occasion and the facility has been observed to smell of urine which poses a potential health, safety, or personal rights risk to persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the January 27, 2026 inspection of ROSELEAF GARDENS?

This was a complaint inspection of ROSELEAF GARDENS on January 27, 2026. 1 citation were issued: 1 Type A (serious).

Were any citations issued to ROSELEAF GARDENS on January 27, 2026?

Yes, 1 citation was issued (1 Type A, 0 Type B). The first citation was for: "87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent..."

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 CCLDView original report

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