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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200873
Report Date: 11/29/2022
Date Signed: 11/29/2022 12:32:27 PM


Document Has Been Signed on 11/29/2022 12:32 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: 125DATE:
11/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:28 AM
MET WITH:Kathleen Knox, AdministratorTIME COMPLETED:
12:45 PM
NARRATIVE
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On this day 11/29/22, Licensing Program Analyst (LPA) C. Lin conducted a case management visit and met with Administrator Kathleen Knox. LPA explained the purpose of the visit.

During an investigation conducted by the Department, LPA observed 2 bottles of chemical supplies in memory care residents room 201 and room 205. Administrator removed bottles from the rooms and instructed staff to lock them up during visit.


Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809 D. Failure to submit proofs of correction (POC) by plan of correction due date and/or any repeat deficiency within a 12-month period may result in civil penalties.

Exit interview conducted with Administrator. LIC809D, Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/29/2022 12:32 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: 11/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/30/2022
Section Cited

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87705 Care of Persons with Dementia
(f)The following shall be stored inaccessible to residents with dementia:
(2)...toxic substances such as....cleaning supplies and disinfectants.
This requirement is not met as evidenced by…
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Based on observation, the licensee did not comply with the section cited above. LPA observed 2 bottles of disinfectant and cleaner in memory care resident's room 201 and 205 which poses an immediate 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: 11/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
LIC809 (FAS) - (06/04)
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