392700803-6-17-2021-27-AS-ABOE-C43QSN-20210617122550

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700803
Report Date: 06/17/2021
Date Signed: 06/17/2021 12:26:04 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 CARE		FACILITY NUMBER:	392700803
ADMINISTRATOR:	KNOLL, LORI		FACILITY TYPE:	740
ADDRESS:	1119 ROSEMARIE LANE		TELEPHONE:	(209) 307-6696
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95207
CAPACITY:	68	CENSUS: 40	DATE:	06/17/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Lori Knoll		TIME COMPLETED:	12:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 06/17/2021 at 8:22am, Licensing Program Analyst (LPA) Ashley Boothe spoke with Administrator, Lori Knoll regarding facility risk assessment questions. Administrator confirmed no staff or residents have experienced symptoms within the last 10 days. At 9:20am, LPA Ashley Boothe arrived unannounced to conduct a required 1-year Annual inspection. LPA met with Administrator and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 68 non ambulatory residents and LPA observed compliance with fire clearance and license. Today's census is 40 of which 7 are Hospice. Five of five staff observed with criminal record clearance in Licensing Information System. LPA observed Administrator Certificate expires on 10/4/2021. LPA interacted with a random number of residents during this visit and observed residents engaging in group activities, an activity calendar posted, and lunch. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed kitchen, restrooms, bedrooms, common living areas and storage areas to be clean in good repair. The temperature inside the facility was measured at 75F which is within the required range of 68F and 85F, or in areas of extreme heat the maximum shall be 30F less than the outside temperature. The hot water was measured at 128F and 129F in resident's restrooms outside of regulatory range which is not less than 105F and not more than 120F. Maintenance staff adjusted hot water heaters down during today's visit. LPA observed the centrally stored medications, knives, kitchen, laundry and staff restroom area to be locked inaccessible to residents. Three of three medications matched MAR, no refused medications. All medications observed properly stored and labeled and unexpired. The first aid kit was found in compliance containing at least the following: a current edition of an approved first aid manual, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. Continued on 809 c.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/17/2021

NARRATIVE

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LPA observed fire extinguisher last inspected on 2/5/2021, smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed ansul system last inspected on 9/29/2020 out of compliance with semi annual maintenance due by 3/29/2020. Administrator contacted to schedule inspection during today's visit. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. LPA observed two soap dispensers not in working order and hand soap accessible to residents. LPA observed COVID precautions signs posted, restrooms stocked with paper towels, hand soap and touchless covered trash can and 30 day supply of PPE stored.

Upon a file review the following items were discussed to be submitted with any changes annually to LPA by 6/30/2021:
Licensing fees
Designation of Administrative Responsibility LIC308
Personnel Report LIC500
Liability Insurance
Emergency Disaster Plan LIC610E

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation and any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report was given.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based observation, the licensee did not comply with the section cited above in that hot water measured at 128F and 129F in resident's restrooms outside of regulatory range which is not less than 105F and not more than 120F. which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/18/2021
	Plan of Correction
1 2 3 4	Hot water heaters adjusted down during today's visit. The licensee agrees to send a picture of hot water temperature measureed within regulatory range to LPA by POC due date.

Type A

Section Cited

CCR

87203

Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that the fixed ansul system scheduled for semi annual inspection was last conducted on 9/29/2020 which poses an immediate health, safety or personal rights risk to persons in care. *Civil Penalty assessed on today's date*
	POC Due Date: 06/21/2021
	Plan of Correction
1 2 3 4	The Licensee scheduled inspection appointment for 6/21/2021 and agrees to submit a photo of tag as proof of inspection once completed.

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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

LIC809 (FAS) - (06/04)

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