Staffing, personnel, and training
Cited in 8 reports, with 10 deficiencies in total.
Apr 8, 2026Mar 23, 2026Jan 27, 2026Apr 22, 2025Oct 29, 2024Jul 10, 2024Mar 5, 2024Jan 29, 2024
ROSELEAF GARDENS
2770 SIERRA LADERA, Chico CA 95928
56 bedsLatest official report Aug 12, 2026Licensed
Additional info
- Telephone
- (530) 630-3042
- Licensee
- GOLDEN ROSELEAF GARDENS OPCO LLC
- Administrator
- HAWKINS, GRACE
- Contact
- HAWKINS, GRACE
- License first date
- Apr 19, 2021
- License effective date
- Apr 19, 2021
- District office
- SACRAMENTO NORTH ASC · (916) 263-4700
- Regional office
- 59
- Clients served
- 985 - RCFE / HOSPICE
Summary
The available records show 27 Type A and 25 Type B deficiencies for this facility.
View enforcement record- Most recent inspection
- Aug 12, 2026
- Most recent deficiency
- Apr 8, 2026
2 later reports, from May 21, 2026 through Aug 12, 2026, recorded no deficiencies, though the records do not say whether they were follow-ups.
What Type A and Type B mean
- Type A
- Violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
- Type B
- Violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care.
Both classifications are published by California CDSS and are shown as published. SeniorLivingFacts does not rename them or add a severity level of its own.
At a glance
Counts cover the five-year public record. Typical figures are the median for the 8 Butte County facilities licensed for 50 or more beds, except where too few exist to state one — those come from facilities with 7 or more beds.
In the available public five-year record, CCLD published 43 reports for this facility: 18 inspections, 22 complaint investigations, and 3 licensing or administrative records.
Those records contain 27 Type A and 25 Type B deficiencies.
0 deficiencies have explicit official correction or clearance evidence in the loaded records.
- Official inspections
- 18
- Recorded deficiencies
- 52
- Type A deficiencies
- 27
- Type B deficiencies
- 25
- Substantiated complaints
- 15
- Repeated topics
- 9
More than the typical 6
3 in the last 12 months
Well above the typical 4
17 in the last 12 months
Well above the typical 1
4 in the last 12 months
Well above the typical 2
13 in the last 12 months
Well above the typical 1
8 in the last 12 months
Last 36 months
Repeated topics
Topics cited in more than one report during the last 36 months. A repeat may show a pattern worth asking about. Each date opens its report below.
Facility condition and maintenance
Cited in 6 reports, with 10 deficiencies in total.
Apr 8, 2026Oct 21, 2025Oct 21, 2025May 27, 2025Mar 18, 2025Mar 5, 2024
Resident rights
Cited in 5 reports, with 5 deficiencies in total.
Basic services and supervision
Cited in 3 reports, with 5 deficiencies in total.
Health conditions and treatments
Cited in 3 reports, with 4 deficiencies in total.
Medical and dental care
Cited in 3 reports, with 3 deficiencies in total.
Dementia care
Cited in 2 reports, with 2 deficiencies in total.
Incident reporting
Cited in 2 reports, with 2 deficiencies in total.
Licensing and administration
Cited in 2 reports, with 2 deficiencies in total.
Official report history
All preserved reports from the most recent to the oldest, sortable by report type.
Complaint
Allegations3 substantiated · 5 unsubstantiated · 0 unfounded · 3 cited
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87411(a)
- Regulation authority
- CCR
What the official deficiency says
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….The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This is evidenced by: Based on observation and interview, the licensee did not ensure that facility staff was sufficient in numbers in that (2) two of (2) residents interviewed stated they had been left unattended after requesting assistance from staff. Additionally, (5) of five (5) staff agreed that the facility did not have enough staff on each shift to properly care for residents, which poses a potential health, safety, or personal rights risk to residents in care.
Official plan of correction
Administrator agrees to submit a LIC 9098 ensuring their understanding of the regulation. Administrator shall submit the form to LPA by end of business on March 30th, 2026. Previous Administrator has provided proof of in-service training conducted on February 19, 2026, addressing this deficiency.
Deadline recorded: Mar 30, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 30, 2026
Correction not verified in available records
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87411(c)(1)
- Regulation authority
- CCR
What the official deficiency says
87411 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 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This is evidenced by: Based on observation and record review, the licensee did not comply with the regulation stated in that one (1) of three (3) staff files reviewed did not have current First Aid training, which poses a potential health, safety, or personal rights risk to residents in care.
Official plan of correction
Administrator agrees to fill out a LIC 9098 ensuring their understanding of the regulation. Administrator shall submit the form to LPA by end of business on March 30th, 2026. Administrator provided proof of staff’s current First Aid training on November 5, 2026. Additionally, Administrator conducted an in-house CPR training for all staff on November 6, 2025 provided by Kiser CPR.
Deadline recorded: Mar 30, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 30, 2026
Correction not verified in available records
Incident reportingType B
- Official classification
- Type B
- Official code
- 87211(a)(1)(A)
- Regulation authority
- CCR
What the official deficiency says
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….(A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. This is evidenced by: Based on observation and record review, the licensee did not comply with the regulation stated in that one (1) resident passed away and the facility failed to inform CCL within seven (7) days, which poses a potential health, safety, or personal rights risk to residents in care.
Official plan of correction
Administrator agrees to fill out a LIC 9098 ensuring their understanding of the regulation. Administrator shall submit the form to LPA by end of business on March 30th, 2026. Administrator has provided LPA with an LIC 624A documenting this resident’s death and has been sending incident reports sufficiently to CCL since being notified of the deficiency in October 2025.
Deadline recorded: Mar 30, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 30, 2026
Correction not verified in available records
Complaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468.1(a)(14)
- Regulation authority
- CCR
What the official deficiency says
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:(14) To have reasonable access to telephones, to both make and receive confidential calls. This is evidenced by: Based on observation and record review, 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/or personal rights risk to residents in care.
Official plan of correction
The licensee agrees to arrange to have a functioning telephone number that can be answered at all times. The licensee shall update their website and Google profile to reflect a current, working, telephone number. Licensee shall infom family/POA of each resident of the new phone number, if deemed necessary. POC shall be completed and licensee/administrator shall inform LPA of changes made by end of business April 20, 2026.
Deadline recorded: Apr 20, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Apr 20, 2026
Correction not verified in available records
Complaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Staffing, personnel, and trainingType A
- Official classification
- Type A
- Official code
- 87411(a)
- Regulation authority
- CCR
What the official deficiency says
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.
Official plan of correction
Administrator agrees to fill out a LIC 9098 ensuring their understanding of the regulation. Administrator shall submit the form to LPA by end of busness on February 2, 2026. Administrator agrees to conduct/provide training pertinent to the regulation. Administrator shall submit an agenda of this training and a signed staff attendance to LPA by end of busness on February 20, 2026.
Deadline recorded: Feb 2, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Feb 2, 2026
Correction not verified in available records
Complaint
Allegations3 substantiated · 1 unsubstantiated · 0 unfounded · 3 cited
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468.1(a)(2)
- Regulation authority
- CCR
What the official deficiency says
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
Official plan of correction
Administrator agrees to conduct/provide training pertinent to the regulation. Administrator shall submit a signed staff attendance to LPA by end of busness on February 20, 2026.
Deadline recorded: Feb 20, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Feb 20, 2026
Correction not verified in available records
Medical and dental careType B
- Official classification
- Type B
- Official code
- 87465(g)
- Regulation authority
- CCR
What the official deficiency says
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,
Official plan of correction
Administrator agrees to conduct/provide training pertinent to the regulation. Administrator shall submit a signed staff attendance to LPA by end of busness on February 20, 2026.
Deadline recorded: Feb 20, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Feb 20, 2026
Correction not verified in available records
Incident reportingType B
- Official classification
- Type B
- Official code
- 87211(a)(1)(D)
- Regulation authority
- CCR
What the official deficiency says
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
Official plan of correction
Administrator agrees to conduct/provide training pertinent to the regulation. Administrator shall submit an agenda of this training and a signed staff attendance to LPA by end of busness on February 20, 2026.
Deadline recorded: Feb 20, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Feb 20, 2026
Correction not verified in available records
Complaint
Allegations1 substantiated · 2 unsubstantiated · 0 unfounded · 1 cited
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87625(b)(3)
- Regulation authority
- CCR
What the official deficiency says
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.
Official plan of correction
Administrator agrees to fill out a LIC 9098 ensuring their understanding of the regulation. Administrator shall submit the form to LPA by end of busness on February 6, 2026.
Deadline recorded: Feb 6, 2026. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Feb 6, 2026
Correction not verified in available records
Complaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Facility condition and maintenanceType A
- Official classification
- Type A
- Official code
- 87303
- Regulation authority
- CCR
What the official deficiency says
87303 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:(B)Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. Based on observations and interviews conducted, the licensee did not ensure the facility's emergency signal system was operable, which poses an immediate health, safety or personal rights violation.
Official plan of correction
The LIcensee/Administrator agrees to have the signall system repaired and operable by end of business on 10/24/25. Licensee/Administrator shall submit video proof to LPA of working pagers by end of business 10/24/25. Until the pagers have been received and programmed, the licensee/administrator agrees to have staff check on residents hourly and staff shall sign off on a physical log of these checks.
Deadline recorded: Oct 23, 2025. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Oct 23, 2025
Correction not verified in available records
Complaint
Allegations1 substantiated · 1 unsubstantiated · 2 unfounded · 1 cited · investigated over 2 visits
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(a)
- Regulation authority
- CCR
What the official deficiency says
87303 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 observations and interviews conducted, the licensee did not ensure that R1's room was clean, safe, and sanitary on at least three (3) seperate dates, which poses a potential health, safety or personal rights violation.
Official plan of correction
Licensee/Administrator shall ensure resident's rooms and belongings are kept sanitary and remain odor free. Licensee/Administrator shall create and submit a plan to licensing to address the consistent unsanitary conditions by end of business October 31, 2025.
Deadline recorded: Nov 4, 2025. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Nov 4, 2025
Correction not verified in available records
Complaint
Part of the complaint whose outcome is recorded on Oct 21, 2025 · Control 59-AS-20250410131635
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 1 unsubstantiated · 0 unfounded · 1 cited
Not classified in the sourceType B
- Official classification
- Type B
- Official code
- 87312
- Regulation authority
- CCR
What the official deficiency says
87312 Motor Vehicles Used in Transporting Residents ....Any vehicle used by the facility to transport residents shall be maintained in a safe operating condition. This requirement was not met as evidenced by: Based on observation, interviews, and records reviewed, the licensee did not ensure that the facility transportation vehicle was in working order which poses a potential health, safety or personal rights violation.
Official plan of correction
Licensee/Administrator agrees to ensure the vehicle is in working order by end of business on October 10, 2025. LIcensee/Administrator shall provide proof of purchase for any parts needed and any addiitonal work done on the vehicle to LPA via email by this date.
Deadline recorded: Oct 10, 2025. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Oct 10, 2025
Correction not verified in available records
Complaint
Allegations4 substantiated · 3 unsubstantiated · 0 unfounded · 4 cited · investigated over 2 visits
No deficiencies recorded in this reportComplaint
Part of the complaint whose outcome is recorded on Mar 25, 2025 · Control 59-AS-20250123105158
Basic services and supervisionType A
- Official classification
- Type A
- Official code
- 87464(d)
- Regulation authority
- CCR
What the official deficiency says
87464 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 as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement was not met as evidenced by: Based on interviews and a review of the resident’s observation log the licensee/administrator did not send the resident out for emergency services. This poses an immediate risk to residents in care.
Official plan of correction
The administrator agrees to write a plan of correction advising how she will avoid this type of citation in the future.
Deadline recorded: Mar 19, 2025. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 19, 2025
Correction not verified in available records
Basic services and supervisionType A
- Official classification
- Type A
- Official code
- 87466
- Regulation authority
- CCR
What the official deficiency says
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. 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. This requirement was not met as evidenced by: Based on interviews and a review of the resident’s observation log the licensee/administrator did not notify the resident’s responsible party, as required. This poses a immediate risk to residents in care.
Official plan of correction
The administrator agrees to write a plan of correction advising how she will avoid this type of citation in the future. Repeat violation, $250. civil penalty.
Deadline recorded: Mar 19, 2025. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 19, 2025
Correction not verified in available records
Basic services and supervisionType B
- Official classification
- Type B
- Official code
- 87464(f)
- Regulation authority
- CCR
What the official deficiency says
Basic Services - Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code Section 1569.2(c). This requirement was not met as evidenced by: Based on interviews and a review of the records, the licensee/administrator did not ensure that residents were receiving their showers as required. This poses a potential risk to residents in care.
Official plan of correction
The administrator agrees to submit to the licensing agency the Personnel Report (LIC 500) advising how she will meet the needs of the residents by increasing staffing.
Deadline recorded: Mar 25, 2025. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 25, 2025
Correction not verified in available records
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(a)
- Regulation authority
- CCR
What the official deficiency says
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 interviews, the licensee/administrator did not ensure that the facility was without clogged toilets and an odor throughout the facility. This poses a potential risk to residents in care.
Official plan of correction
The administrator agrees to write a plan of correction advising how she will avoid this type of citation in the future.
Deadline recorded: Mar 25, 2025. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 25, 2025
Correction not verified in available records
Complaint
Allegations1 substantiated · 4 unsubstantiated · 0 unfounded · 1 cited
Basic services and supervisionType A
- Official classification
- Type A
- Official code
- 87466
- Regulation authority
- CCR
What the official deficiency says
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. 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. This requirement was not met as evidenced by: Based on observation of records and interviews that were conducted by the Department of Social Services-Community Care Licensing Division-Investigations Branch, Investigator Blatnick, the facility did not seek any other medical options or communicate with the doctor regarding the resident’s condition which presents an immediate health, safety, and personal rights risk to the residents in care.
Official plan of correction
Licensee/Administrator shall conduct staff training and provide proof of that training to Community Care Licensing. In addition, Licensee/Administrator shall fill out an LIC 9098-Self-Certification understanding of the regulation. Licensee/Administrator shall also provide a statement on how future compliance will be met. POC due date February 13, 2025
Deadline recorded: Feb 13, 2025. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Feb 13, 2025
Correction not verified in available records
Complaint
Allegations1 substantiated · 4 unsubstantiated · 0 unfounded · 1 cited
Licensing and administrationType A
- Official classification
- Type A
- Official code
- 1569.2
- Regulation authority
- HSC
What the official deficiency says
Health and Safety Code §1569.2 (c) “Care and supervision” means the facility assumes responsibility for, or provides or promises to provide in the future, 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 an observation of facility records and an interview with the Administrator, the facility Care Notes reflected that the bathing was not documented as being completed with no proof that the resident ever denied the showers. LPA conducted an interview with the Administrator via email and learned that the facility has no corroborating evidence to support that the resident denied the showers during said dates which is an immeidate health, safety and personal rights risk to the residents in care.
Official plan of correction
Licensee/Administrator to submit an LIC 9098 understanding of the Health and Safety Code Regulation. In addition, Licensee and Administrator shall conduct staff training outlining the regulations surrounding Care and Supervision. Licensee/Administrator shall provide a statement on how future compliance will be met. POC due date: November 14, 2024
Deadline recorded: Nov 14, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Nov 14, 2024
Correction not verified in available records
Complaint
Allegations2 substantiated · 0 unsubstantiated · 0 unfounded · 2 cited
Staffing, personnel, and trainingType A
- Official classification
- Type A
- Official code
- 87411(a)
- Regulation authority
- CCR
What the official deficiency says
Personnel Requirements – Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs or the physical arrangements of the facility require such additional staff for the provision of adequate services. The requirement is not met as evidence by: Based on record review, the licensee did not provide adequate care and supervision by leaving a dementia resident unsupervised outside for an extended period which poses an immediate Health, Safety, Personal Rights risk to persons in care.
Official plan of correction
The licensee/administrator agrees to submit to the licensing agency a plan for each resident that is a fall risk. Advise the type of prevention, escort services needed, and training materials that will be used to inform the staff. A civil penalty in the amount of $1000.00 will be served this date, as the facility has been cited two times; dates 07/10/24 and 10/29/24.
Deadline recorded: Oct 30, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Oct 30, 2024
Correction not verified in available records
Dementia careType A
- Official classification
- Type A
- Official code
- 87705(c)(3)(A)
- Regulation authority
- CCR
What the official deficiency says
Care of Persons with Dementia – Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: Dementia care including, but not limited to, knowledge about hydration, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living. Based on record review, the licensee did not provide adequate care and supervision by leaving a dementia resident unsupervised outside for an extended period which poses an immediate Health, Safety, Personal Rights risk to persons in care.
Official plan of correction
The licensee/administrator agrees to submit to the licensing agency what plan is in place to ensure that the residents are being hydrated each day.
Deadline recorded: Oct 30, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Oct 30, 2024
Correction not verified in available records
Complaint
Allegations0 substantiated · 5 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Licensing and administrationType B
- Official classification
- Type B
- Official code
- 1569.2(c)
- Regulation authority
- HSC
What the official deficiency says
Care and supervision” means the facility assumes responsibility for, or provides or promises to provide in the future, 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: The resident was not assisted with dressing as an expressed need outlined in residents medical assessment, preapprasial and care plan from 3/11-3/15/2024, four days without assistance with dressing.
Official plan of correction
Facility agrees to create a plan to ensure that, residents are receiving the care outlined within their needs and services plan. Facility will ensure that staff are documenting the completion of the needs and services outlined in resident care plans. Facility will also conduct a training with staff regarding the importance of resident observation and documentation of ADLs and submit to LPA by the POC due date of 05/02/24.
Deadline recorded: Apr 25, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Apr 25, 2024
Correction not verified in available records
Complaint
Allegations3 substantiated · 0 unsubstantiated · 0 unfounded · 2 cited
Medical and dental careType A
- Official classification
- Type A
- Official code
- 87465(a)(6)
- Regulation authority
- CCR
What the official deficiency says
Incidental Medical - 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: When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement was not met as evidenced by interviews and documentation review. The licensee failed to ensure that a prescription order was in place to crush a resident’s medication. This poses an immediate health and safety risk to residents in care.
Official plan of correction
Administrator agrees to ensure that a physician’s order is in place to alter or crush a resident’s medication. The administrator will submit a copy of her understanding to the licensing agency
Deadline recorded: Mar 20, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 20, 2024
Correction not verified in available records
Resident rightsType A
- Official classification
- Type A
- Official code
- 1569.269(a)(6)
- Regulation authority
- HSC
What the official deficiency says
Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) 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 interviews and documentation review. The licensee failed to comply with the Health and Safety code cited above. A fall risk care plan was not in place. This poses an immediate health and safety risk to residents in care.
Official plan of correction
The administrator agrees to assess all residents that are a fall risk and prepare a plan. Training shall be provided to care providers regarding prevention practices of residents that are a fall risk. The administrator agrees to submit to the licensing agency the materials used to train the care providers and a sign in sheet of those that were trained.
Deadline recorded: Mar 20, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Mar 20, 2024
Correction not verified in available records
Complaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Staffing, personnel, and trainingType A
- Official classification
- Type A
- Official code
- 87411(a)
- Regulation authority
- CCR
What the official deficiency says
87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs or the physical arrangements of the facility require such additional staff for the provision of adequate services. The requirement is not met as evidence by: Based on observation, interviews and record review, the licensee did not provide adequate care and supervision by leaving a dementia resident unsupervised outside for an extended period of time which poses an immediate Health, Safety, Personal Rights risk to persons in care.
Official plan of correction
Licensee agrees to provide training for all direct care and administrative staff on the requirement to seek medical attention timely for residents. Licensee will schedule the training and provide CCL with the training content and signed staff attendance sheet as proof of correction.
Deadline recorded: Feb 2, 2024. A deadline is not proof that correction was completed.
Plan of correction recorded
Correction deadline recordedDeadline Feb 2, 2024
Correction not verified in available records
Complaint
Allegations0 substantiated · 2 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 1 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportEnforcement records
Revocation Action Pending
Pleading date: Jul 9, 2026 · Case closed: No
Source and limits
California Department of Social Services, Community Care Licensing Division. Public facility history is described by the source as a five-year window. Older records and previous-licensee history may require a regional-office request. Type 741 RCFE-CCRCs, nursing homes, and other care settings are excluded from this page.
Read the data methodology