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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700803
Report Date: 03/16/2021
Date Signed: 03/16/2021 03:19:38 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/17/2020 and conducted by Evaluator Ashley Boothe
COMPLAINT CONTROL NUMBER: 27-AS-20201117113820
FACILITY NAME:ROSE PLACE MEMORY CAREFACILITY NUMBER:
392700803
ADMINISTRATOR:KNOLL, LORIFACILITY TYPE:
740
ADDRESS:1119 ROSEMARIE LANETELEPHONE:
(209) 307-6696
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:68CENSUS: 39DATE:
03/16/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Lori KnollTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff are not adequatly assisting resident with medications resulting in consistent high blood sugar levels.
Staff are falsyfing resident records.
INVESTIGATION FINDINGS:
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On 3/16/2021 at 11:30am Licensing Program Analyst (LPA) Ashley Boothe contacted Administrator (ADM) Lori Knoll and stated the purpose of the visit to deliver the findings of a complaint investigation with the allegations: Resident is not adequately assisting the resident with nutritional needs, resulting in weight loss and staff are falsifying resident records. A physical visit was not conducted in that the Department is not conducting visits due to COVID-19. Current Census 39. A & A Senior Living Management was the management company through 10/31/2020. West Bay Senior Living is the current management company from 11/1/2021.

During the investigation, LPA conducted interviews and reviewed documents provided by the Investigation Bureau (IB) Report, findings of the IB report, Resident one (R1)’s Admissions Agreement dated 10/25/2020, R1’s Physician's Report LIC 602 dated 7/15/2020, R1’s St. Joseph’s Medical Center-Stockton Discharge instructions dated 7/13/2020, R1’s Medication Administration Records (MAR's) dated 5/1/2020-11/30/2020 and R1's Centrally Stored Medication Log.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20201117113820
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 392700803
VISIT DATE: 03/16/2021
NARRATIVE
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Continued from 9099.

Based on record review and interviews R1 did lose weight while living at the facility, but not due to lack of nutritional needs from the facility staff. R1 contracted COVID while living at the facility, as a result, R1 lost some weight due to illness. R1’s roommate passed away shortly after contracting COVID. According to staff R1 seemed sad after his roommate passed and refused to eat for about a weeks time. All staff report R1 being a great eater. Documents and interviews R1 was served three meals daily, snacks in between, and nutritional shake to be given daily after each meal per physician’s orders. MAR’s note five incidents of nutritional shakes not given but not documented if R1 refused or staff missed administration. R1 can tell staff if he is hungry and will often times ask for snacks.



Based on interview the previous management was not weighing R1 like they said they were, which made it seem as if R1 had lost a lot of weight in a short period of time. R1 was weighed monthly along with other residents. Physicians report on 7/15/2020 shows R1 weight at 181.2 pounds. Per the weight log from the facility R1 weighed 9/20/2020 at 173.8 pounds, 10/14/2020 173.1 pounds, 11/13/2020 155 pounds, 11/16/2020 153 pounds. R1 and two residents of the facility stated the facility takes good care of them, feeds them well, and had no complaints against the facility.

Based on information obtained the aforementioned allegations are UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

There are no deficiencies being cited per Title 22 Regulations. Exit interview was conducted with Lori. Copy of the report was sent to via e-mail with a "read receipt" to verify the LIC 9099, 9099 C, and Appeal Rights were received. Lori is to print out the report and fax signed copies to LPA at 916-263-4744 or email to LPA at ashley.boothe@dss.ca.gov.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/17/2020 and conducted by Evaluator Ashley Boothe
COMPLAINT CONTROL NUMBER: 27-AS-20201117113820

FACILITY NAME:ROSE PLACE MEMORY CAREFACILITY NUMBER:
392700803
ADMINISTRATOR:KNOLL, LORIFACILITY TYPE:
740
ADDRESS:1119 ROSEMARIE LANETELEPHONE:
(209) 307-6696
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:68CENSUS: 39DATE:
03/16/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Lori KnollTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
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9
Staff are not adequatly assisting resident with medications resulting in consistent high blood sugar levels.
Staff is not following doctor's orders.
INVESTIGATION FINDINGS:
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5
6
7
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10
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13
On 3/16/2021 at 11:30am Licensing Program Analyst (LPA) Ashley Boothe contacted Administrator (ADM) Lori Knoll and stated the purpose of the visit to deliver the findings of a complaint investigation with the allegations: Resident is not adequately assisting the resident with nutritional needs, resulting in weight loss and staff are falsifying resident records. A physical visit was not conducted in that the Department is not conducting visits due to COVID-19. Current Census 39. A & A Senior Living Management was the management company through 10/31/2020. West Bay Senior Living is the current management company from 11/1/2021.

During the investigation, LPA conducted interviews and reviewed documents provided by the Investigation Bureau (IB) Report, findings of the IB report, Resident one (R1)’s Admissions Agreement dated 10/25/2020, R1’s Physician's Report LIC 602 dated 7/15/2020, R1’s St. Joseph’s Medical Center-Stockton Discharge instructions dated 7/13/2020, R1’s Medication Administration Records (MAR's) dated 5/1/2020-11/30/2020 and R1's Centrally Stored Medication Log.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20201117113820
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 392700803
VISIT DATE: 03/16/2021
NARRATIVE
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Continued from 9099 A.

LPA observed R1’s physician’s assessment to state R1 can administer own injections but requires assistance with monitoring blood glucose levels. LPA observed instances where R1’s blood glucose monitor was noted on the MAR’s machine not working from 10/24/2020 to 10/31/2020. LPA observed instances of sugar levels above 400 on 11/2/2020, 11/6/2020, 11/9/2020, 11/10/2020 and below 70 on 11/13/2020 with physician’s orders to notify physician. Interview with R1’s physician’s office stated R1’s chart did not document notification from facility of R1’s levels outside of range. Records reviewed document Lantus prescribed by physician’s order one tablet evening on Centrally Stored Medications Log starting on 10/8/2019. R1 was not administered Lantus on MAR's reviewed. St. Joseph’s Discharge instructions on 7/13/2020 next dose 7/13/2020 at bedtime not administered on MAR's reviewed. New physician's order on 11/12/2020 not administered to R1 as it was awaiting delivery from 11/13/2020 to 11/17/2020. Staff one (S1) interview stated R1 was missing his nightly medication for about four months until S1 noted it. R1 is prescribed a nutritional shake to be given one shake after every meal. LPA observed five instances of shake not given and one note to hold shake due to the wrong shake delivered from the pharmacy per Power of Attorney’s instruction on MAR's reviewed.



Based on information obtained the aforementioned allegations are SUBSTANTIATED. A finding that the complaint is substantiated means the preponderance of evidence standard has been met, therefore the allegation(s) is found to be substantiated.

Deficiencies are being cited per Title 22 Regulations. Exit interview was conducted with Lori. Copy of the report was sent to via e-mail with a "read receipt" to verify the LIC 9099A, 9099 C, and 9099D, and Appeal Rights were received. Lori is to print out the report and fax signed copies to LPA at 916-263-4744 or email to LPA at ashley.boothe@dss.ca.gov.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20201117113820
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 392700803
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/17/2021
Section Cited
CCR
87465(a)(5)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (5)The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidence by:
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Licensee agrees to submit a plan to be in compliance with this regulation at all times by POC due date of 3/17/2021.Licensee agrees to submit a plan to be in compliance with this regulation at all times by POC due date of 3/17/2021.
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Based on records review and interview the licensee did not assist R1 with administering medications as physician’s orders as noted on MAR’s and did not notify R1’s physician when R1’s blood glucose was above 400 or below 70 as ordered which poses an immediate health and safety 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5