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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700803
Report Date: 08/27/2020
Date Signed: 08/27/2020 04:01:45 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ROSE PLACE MEMORY CAREFACILITY NUMBER:
392700803
ADMINISTRATOR:GREWAL, KAMALFACILITY TYPE:
740
ADDRESS:1119 ROSEMARIE LANETELEPHONE:
(209) 307-6696
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:68CENSUS: 40DATE:
08/27/2020
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Kamal Grewal, AdministratorTIME COMPLETED:
03:00 PM
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Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Ashley Boothe, Licensing Program Analyst (LPA) Diego Escobar, and Ombudsman Coordinator, Jill Hernandez met with facility representatives, Kamal Grewal, Raj Thandi, and Betty Dominici. LPM explained the purpose of this office meeting is to discuss the recent complaints received by CCLD against Rose Place Memory Care and to review facility operation procedures.

Facility procedures discussed during the meeting were:
1. Notifications to responsible parties
2. Facility call system
3. Staffing ratios
4. Care and supervision
6. Incidental medical and dental care
7. Reporting Requirements

Exit interview was conducted with Kamal, Betty, and Raj. Copy of the report sent to Kamal via e-mail with a "read receipt" to verify the LIC 809 was received. Kamal is to print out the report and fax a signed copy to LPA at 916-263-4744.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Diego EscobarTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2020
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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