<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700803
Report Date: 08/03/2021
Date Signed: 08/03/2021 03:16:23 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: 45DATE:
08/03/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Lori KnollTIME COMPLETED:
03:25 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 8/3/2021 at 1:55pm, Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a case management visit. LPA met with Administrator Lori Knoll and explained the purpose of today’s visit. Prior to today's visit LPA contacted regarding facility risk assessment questions. Administrator confirmed no staff or residents have experienced symptoms within the last 10 days. Current census is 45.

LPA reviewed training records for facility staff. LPA requested personnel records for in service training from the April 2020 to current. LPA observed training records incomplete and not signed off by staff, missing information such as date, topic, and trainer. Records reviewed during the time period include falsified documents found to include photocopies of sign off sheets with staff signatures and incomplete information. Records of online training completed in Relias not available for LPA review. Administrator contacted the management company who would not able to compile records at Administrator's request. Administrator was denied access to prior management company's Relias account as of 10/31/2020 upon termination of management company contract. LPA reviewed Administrator's last Relias record as of 10/19/2020 with initial and continuing education staff training marked "not started" for multiple staff working in the facility at the time. LPA reviewed two of two staff files hired in May 2020 to not include initial training recorded.

Administrator has training records documented from January 2021 forward, all found to be maintained and recorded in personnel records and in service training logs using a variety of training platforms, found in compliance at this time. Administrator has a new Relias account opened in January 2021.

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: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
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 2
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: 08/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/11/2021
Section Cited

1
2
3
4
5
6
7
87411 Personnel Requirements - General (d) All personnel shall be given on the job training.... This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:
This requirement is not met as evidence by:
8
9
10
11
12
13
14
Based on observation, interview, and record review the licensee did not comply with the section cited above in that staff was not provided job training during initial or continuing education for job performance during the time prior to January 2021 which posed/poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: 08/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2