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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 150400536
Report Date: 11/03/2021
Date Signed: 11/04/2021 08:26:53 AM

Document Has Been Signed on 11/04/2021 08:26 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:ROSEWOOD RETIREMENT COMMUNITYFACILITY NUMBER:
150400536
ADMINISTRATOR:BALABAN, ROCHELLEFACILITY TYPE:
741
ADDRESS:1301 NEW STINE ROADTELEPHONE:
(661) 834-0620
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 220CENSUS: 151DATE:
11/03/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rochelle Balaban, Administrator
Griscel Garcia, Memory Care Manager
Faith Enriquez, Lead LVN 		TIME COMPLETED:
05:45 PM
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On 11/3/21 at 10:00 AM, Licensing Program Analyst (LPAs) Malia Thao and Lisa Salazar arrived unannounced to conduct a case management - deficiencies inspection.

LPAs observed the following deficiencies:

1. Steak knife out on the counter in the kitchen of the third floor, unsupervised. LPA Malia Thao observed food service staff walk out of kitchen/dining room, then LPAs entered kitchen/dining area with LVN Faith Enriquez and observed steak knife out on counter. While touring the memory care unit, LPAs observed from the hallway a disinfecting spray bottle on top of toilet tank in Room 244. Room 244's door was open, and disinfecting spray was accessible to room's resident as well as all other passing residents.

2. LPA found that R2 is diagnosed with dementia and last had a medical assessment completed on 2/20/2020.

3. R6's medical assessment form LIC602A did not include the resident's primary or secondary diagnosis.

Deficiencies are being cited based on LPA observations, interviews conducted, and records review in accordance with the California Code of Regulations, Title 22, see LIC809D.

Exit interview conducted. A copy of this report and appeal rights were emailed to email on record with Read receipt to confirm receipt of this report.

SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2021
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 11/04/2021 08:26 AM - It Cannot Be Edited


Created By: Malia Thao On 11/03/2021 at 04:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: ROSEWOOD RETIREMENT COMMUNITY
FACILITY NUMBER: 150400536

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2021
Section Cited
CCR
87309(a)

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87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
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Administrator locked door to 3rd floor kitchen and removed the disinfecting spray from Room 244 during the inspection. POC cleared.
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LPA found steak knife out on the counter in the kitchen of the third floor, unsupervised. LPA Malia Thao observed food service staff walk out of kitchen/dining room, then LPAs entered kitchen/dining area with LVN Faith Enriquez and observed steak knife out on counter. While touring the memory care unit, LPAs observed from the hallway, a disinfecting spray bottle on top of toilet tank in Room 244. Room 244's door was open, and disinfecting spray was accessible to room's resident as well as all other passing residents. This poses an immediate health, safety, and personal rights risk to residents in care.
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Type B
11/17/2021
Section Cited
CCR87705(c)(5)

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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 as specified in Section 87458, Medical Assessment.. both of which shall include a reassessment of the resident’s dementia care needs.

This requirement is not met as evidenced by:
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Administrator will submit proof of a new medical assessment completed for R2 to CCL by POC due date.
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LPA found that R2 is diagnosed with dementia and last had a medical assessment completed on 2/20/2020. This poses a potential health, safety, or personal rights risk to residents 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:Andy Xiong
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/04/2021 08:26 AM - It Cannot Be Edited


Created By: Malia Thao On 11/03/2021 at 04:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: ROSEWOOD RETIREMENT COMMUNITY
FACILITY NUMBER: 150400536

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2021
Section Cited
CCR
87458(b)(1)

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87458 Medical Assessment (b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis...other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
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Administrator will submit proof of new medical assessment completed to show R6's primary and secondary diagnosis to CCL by POC due date.
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LPA found that R6's medical assessment form LIC602A did not include the resident's primary or secondary diagnosis. This poses a potential health, safety, and personal rights risk to residents 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:Andy Xiong
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2021


LIC809 (FAS) - (06/04)
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