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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700803
Report Date: 08/30/2021
Date Signed: 08/30/2021 04:41:52 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: 44DATE:
08/30/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Serena VillanuevaTIME COMPLETED:
04:55 PM
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On 8/30/2021 at 3pm, Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Health and Safety Visit. LPA met with Designated Staff (S1) and explained the purpose of today’s visit. LPA was allowed entry into the facility, current census is 44.

As of today 5 residents tested positive and 4 staff tested positive for COVID-19. Currently all residents are under isolation order due to the outbreak. The physical plant was toured to ensure the safety of the residents. LPA observed positive residents chorted in Red Zone and all other residents in Yellow Zone for mitigation of COVID outbreak. LPA provided technical assistance to place isolation carts, covered touchless trash cans, PPE donning, stop signs, and all staff must wear N95 at both entrances of partitioned Red Zone and designate staff to the Red Zone. LPA observed residents in the facility's common areas and observed staff redirect residents back to their rooms, to keep doors closed, and wear a mask. LPA observed visitors are screened outside the front door and S1 stated staff are rapid tested prior to the start of the shift, but they had run out of tests and the Licensee was sending more. Currently the facility short staff but is operating with extended shifts to cover all hours and a staffing agency contract was signed today to support staffing needs. LPA observed disinfectant spray with 30 sit time and wipes available to staff. S1 stated they are disinfecting as frequently as possible and one housekeeping staff is on site daily except Sundays. LPA observed PPE to be less than 30 day supply and S1 stated Licensee is sending additional supplies. LPA delivered PPE supplies from the regional office during today's visit and provided technical assistance for all staff to wear an N95 not KN95 in the facility at all times. 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. Food was last delivered last Wednesday and another order will be delivered this upcoming Wednesday, currently only using US Foods for delivery.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
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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