Inspection visit

complaintApril 8, 2022

ROSELEAF SENIOR CARELicense 0450027781 citation on this visit

1 citation recorded

Inspector’s narrative

What the inspector wrote

This Department reviewed two resident files and found both residents were incontinent. During staff interviews, staff stated due to resident behaviors and lack of training with those behaviors, residents did not have their briefs changed. This department reviewed the “reported care report” and “Observations” which were authored by staff submitted to CCLD by the facility. This department observed that R1 last received incontinent care on 12/19/21 at 9:21 PM. On 12/20/21 at 05:18 AM, MT documents, “(R1) SLEPT MOST OF THE NIGHT I TRIED TO HELP R1 CHANGE BUT NO LUCK, AM SHIFT WILL BE INFORM AND WILL TRY.” The next entry is on 12/20/21 at 1203 PM which states, “Resident has refused care all day, but this writer did manage to change Resident's bedding. MT will try to later change Resident's brief.” The subsequent 3 entries are similar. Its not documented until 12/21/21 at 2:17 PM that R1 was changed, “Resident's bedding was fully changed and socks, pants and briefs as well.” However, on 12/21/21 at 11:33 PM its documented, “Resident had refused to allow PM shift staff to provide care despite being visibly saturated in urine. During shift change Med Tech was able to change resident and RA was able to provide bedding change during that time as well.” On the Recorded Care Chart for R2 (Resident 2) observed on 12/21/21 at 11:04PM, incontinence care was completed. Incontinence care does not show completed again until 12/22/21 at 2:31 PM. The reasons listed by staff for not having completed incontinence care state, “Resident refused attempt to provide care, Resident refused becoming agitated and aggressive, etc..” 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. Only administrative staff were able to provide ways that they can redirect to provide incontinence care. Care giving staff reported they are not trained in providing incontinence care to combative residents although Executive Director provided demonstrations with R1. 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. 1 citation were issued: 1 Type A (serious).

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

Yes, 1 citation was issued (1 Type A, 0 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 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·April 8, 2022