Skip to main content
ReadyRule homepageReadyRule

Inspection visit

complaint

ROSELEAF SENIOR CARELicense 0450027783 citations on this visit
3 citations recorded

Inspector’s narrative

What the inspector wrote

Roseleaf Senior Care is a facility that primarily accepts residents with diagnosis related to memory care. Interviews revealed NOC shift only has one caregiver who is med tech trained on at a time. AM Staff reported they would often come in and find R1 and R2 saturated in urine. Review of records indicated NOC was not providing incontinence care to all residence during an 8-hour shift. Staff reported there were 2-3 residents who required a 2 person assist and had a Hoyer lift. Staff said the policy for the Hoyer lift is that 2 people are required to operate it. Although the Licensee retained residents who requires 2 staff to assist, the facility only scheduled 1 person during NOC shift. Interviews and review of documents revealed on 12/2/2021, a med tech was transferring a hospice resident (R1) from R1’s bed to wheelchair. R1 was a two person transfer however R1 transferred resident without the assistance of another staff member. This resulted in R1 falling sustaining a bloody nose, a skin tear to R1’s neck, and wrist. Due to R1 being on hospice, R1 was not transferred out and treated by Hospice staff at the facility. The facility has experienced two COVID outbreaks, the first being with staff in August 2021 and the 2 nd being in January and February of 2022. The 2 nd outbreak consisted of multiple residents. Instead of isolating residents in their rooms, the facility due to lack of staffing, sent residents out to Colusa Medical Center for their isolation period regardless of being asymptomatic or having mild symptoms. Interviews and LPA observation revealed activities were not being provided from August until November 2021 due to lack of staffing. Interviews revealed the facility maintained 1 med tech and 1 caregiver during AM and PM shifts however there was not consistently a cook at the facility or activities being done. On 7/31/21 and 8/1/21, this department conducted a health and safety check due to the facility self-reporting a staffing shortage. During these visits, this department observed residents sitting in silence, in a circle facing each other for hours. The facility said they were utilizing activities staff for care giving. Cont'd 9099-C Interviews conducted revealed staff did not know who the listed administrator was to include what Darrin Tristal’s role was at the facility. Most staff had not met him. At the time of this complaint Licensee Peer Services had Darrin Tristal listed as administrator. The Chico Regional Office, who provides oversight to Roseleaf Senior Care, requested copies of documents to list Executive Director Eric Perry as administrator however Darrin refused due to providing requested documents during the application process with the Centralized Application Unit. In January 2022, Peer Services requested to list Samantha Guriano as the Administrator. Substantiated Based on the departments 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. 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.

Citations

7 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.

  • 87219(a)Type A

    87219(a)-Planned Activities-Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities.This requirement is not met as evidenced by: Based upon observation and interview the Licensee failed to provide all residents in care with the opportunity to participate in planned activities.This poses an immediate Health, Safety and/or Personal Rights risk to residents in care.

  • 87405(h)(8)Type B

    87405(h)(8) Administrator - Qualifications and Duties-The administrator shall have the responsibility to: Have the personal characteristics, physical energy and competence to provide care and supervision and, where applicable, to work effectively with social agencies. This requirement is not met as evidenced by: Based upon observation and interview the Licensee failed to have an administrator with the personal characteristics, competence and ability to work effectively with social agencies.This poses a potential Health, Safety and/or Personal Rights risk to residents in care

  • 87411(a)Type A

    87411(a) Personnel Requirements – General-Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.This requirement is not met as evidenced by: Based upon observation and interview the Licensee failed to ensure staff are sufficient in numbers and competent to provide services necessary to meet resident needs.This poses an immediate Health, Safety and/or Personal Rights risk to residents in care.

  • 87211(a)(1)(D)Type B

    87211(a)(1)(D)-Reporting requirements- A written report shall be submitted to the licensing … within 7 days of the occurrence …Report shall include resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Any incident which threatens the welfare, safety or health of any resident.This requirement was not met as evidenced by interview and record review: Licensee failed to report injuries and hospitalization of 1 of 1 residents in care. This poses a potential risk to the health and safety of residents in care

  • 87466Type A

    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.This requirement was not met as evidenced by: Based on record review and interviews, Licensee did not observe for changes and provide appropriate assistance to those changes for 1 of 1 resident which poses an immediate health and safety risk for resident in care.

  • 87468.2(a)(4)Type A

    87468.2(a)(4)-Additional Personal Rights of Residents in Privately Operated Facilities-residents...shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs This requirement was not met as evidenced by: Based on record review and interviews, Licensee did not provide resident's right to care, supervision and services for 1 of 1 residents in care. This poses an immediate health and safety risk for resident in care.

  • 87625(b)(3)Type A

    87625(b)(3) Managed Incontinence- In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dryThis requirement is not met as evidenced by: Based upon record review and interview the Licensee failed to ensure 2 of 2 residents were kept clean and dry.This poses a potential Health, Safety and/or Personal Rights risk to clients in care

FAQ · About this visit

Common questions about this visit

What happened during the April 8, 2022 inspection of ROSELEAF SENIOR CARE?

This was a complaint inspection of ROSELEAF SENIOR CARE on April 8, 2022. 3 citations were issued: 2 Type A (serious) and 1 Type B.

Were any citations issued to ROSELEAF SENIOR CARE on April 8, 2022?

Yes, 3 citations were issued (2 Type A, 1 Type B). The first citation was for: "87219(a)-Planned Activities-Residents shall be encouraged to maintain and develop their fullest potential for independen..."

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

Share this reportEmail

Next steps

If this is your facility,claim this pageand correct anything the record gets wrong. Free.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

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