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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200873
Report Date: 02/06/2023
Date Signed: 02/06/2023 01:24:29 PM


Document Has Been Signed on 02/06/2023 01:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:POINT AT ROCKRIDGE, THEFACILITY NUMBER:
019200873
ADMINISTRATOR:KNOX, KATHLEEN LFACILITY TYPE:
740
ADDRESS:4500 GILBERT STREETTELEPHONE:
(510) 658-9266
CITY:OAKLANDSTATE: CAZIP CODE:
94611
CAPACITY:186CENSUS: 123DATE:
02/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:42 AM
MET WITH:Laura Benson, Interim Executive DirectorTIME COMPLETED:
01:35 PM
NARRATIVE
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On 2/6/23 at 11:42 am, Licensing Program Analyst (LPA) Catherine Lin conducted case management, met with interim executive director (ED) and explained the purpose of visit.

During the course of investigation on a complaint, the Department observed the following deficiencies.

· Staff did not update needs & service plan (LIC625) when R1's health condition was changed.

· Staff did not have annual needs & service plan (LIC625) for residents.

· Staff did not have annual physician’s report for residents who were diagnosed dementia.

· Staff did not report incidents to licensing when resident R1 sustained falls and was admitted to hospital on 11/7/22 and 11/8/22. This is a repeating violation, a civil penalty $250 is assessed on today’s day.

Deficiencies are cited per Title 22 California Code of Regulations. Please refer to LIC 809D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12-month period may result in civil penalty.

Exit interview conducted with ED, Appeal Rights and a copy of this report were provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 02/06/2023 01:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: POINT AT ROCKRIDGE, THE
FACILITY NUMBER: 019200873

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/20/2023
Section Cited

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87463 Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate….
This requirement is not met as evidenced by…
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Administrator agrees to review and understand regulation, retrain staff, and submit in-service training with staff signatures to CCL by the POC due date.
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Based on records review and interview, the licensee did not comply with the section cited above. LPA observed staff didn’t reappraise resident when resident was admitted to hospital two times in 24 hours which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
02/20/2023
Section Cited

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87463 Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident’s representative…once every 12 months…
This requirement is not met as evidenced by…
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Administrator agrees to review and understand regulation, retrain staff, and submit in-service training with staff signatures to CCL by the POC due date.
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Based on records review and interview, the licensee did not comply with the section cited above. LPA observed staff didn’t reappraise resident annually which poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 02/06/2023 01:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: POINT AT ROCKRIDGE, THE
FACILITY NUMBER: 019200873

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/13/2023
Section Cited

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87211 Reporting Requirements
(a) Each licensee shall...including, but not limited to...(1)A written report shall be submitted to the licensing agency...
(D) Any incident...welfare, safety or health of any resident...
This requirement is not met as evidenced by…
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Administrator agrees to review the regulation, and submit a self-certification of understanding regulation to CCL by the POC due date.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA observed resident's falls resulted to be admitted to hospital twice on 11/7/22 and 11/8/22 were not reported to CCLD which poses a potential health and safety concern to persons in care.
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A civil penalty of repeating violation $250 is assessed today.
Type B
02/20/2023
Section Cited

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87705 Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(5) Each resident with dementia shall have an annual medical assessment…
This requirement is not met as evidenced by…
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Administrator agrees to review and understand regulation, retrain staff, and submit in-service training with staff signatures to CCL by the POC due date.
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Based on records review and interview, the licensee did not comply with the section cited above. LPA observed staff didn’t update physician’s report for residents with dementia annually which poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3