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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700803
Report Date: 06/17/2021
Date Signed: 06/17/2021 12:11:00 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:KNOLL, LORIFACILITY TYPE:
740
ADDRESS:1119 ROSEMARIE LANETELEPHONE:
(209) 307-6696
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:68CENSUS: 40DATE:
06/17/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Lori KnollTIME COMPLETED:
12:40 PM
NARRATIVE
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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 case management visit for an incident of Resident one (R1)'s elopement. LPA met with Administrator and explained the purpose of today’s inspection. Today's census is 40 of which 7 are Hospice residents.

LPA observed residents engaged in activities and toured the facility. LPA observed alarms functioning in the community. LPA tested alarms at front door and back exits, all alarms functioning. LPA observed room where R1 eloped. Incident report submitted stated R1 was last seen at 9:15am and staff did not observe R1 at 9:30am, R1 removed the screen and window from another resident's bedroom. Staff immediately contacted local law enforcement, R1 was retuned 50 minutes later after being found approximately one half mile from the facility. Responsible party notified. LPA reviewed physicians report stated R1 can not leave unassisted, preadmission appraisal R1 had previous behaviors of attempting to leave and had just moved in and was placed in a courtyard facing room because of elopement risk. R1 was put on 1:1 care after the incident. LPA observed resident reappraisal and care plan dated 4 days after the incident to include care plan for new behaviors. LPA observed staff schedule of 3 caregivers, 1 med tech, and 7 other staff on site during the incident.

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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/18/2021
Section Cited

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Basic Services (f) Basic services shall at a minimum include:(1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement is not met as evidence by:
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Based on record review and interview R1 had a known risk of elopment and the facility did not adequatly supervise R1 which allowed R1 to elope from the facility which possess 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: 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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