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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700803
Report Date: 08/31/2021
Date Signed: 08/31/2021 04:46:15 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:
08/31/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:William LaskyTIME COMPLETED:
01:30 PM
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On 8/31/2021 at 12:30pm Licensing Program Manager's (LPM's) Liza King, Czarrina Camilion-Lee and Stephanie Doub and Licensing Program Analyst (LPA) Ashley Boothe met with Licensee William Lasky for an announced office visit via Microsoft Teams to discuss facility operations, financial situation, and COVID outbreak.

Currently the facility is operating without an Administrator available to be on site and the Licensee stated a new Administrator will be arriving tomorrow to provide oversight. PPE supplies have been shipped to the facility today including an additional 500 COVID rapid tests for staff to use daily prior to starting shift and gowns scheduled to arrive Thursday. Staffing agency contract has been signed for additional staffing support to address staff shortages. The licensee reported payments have been made for July invoices and additional payments will be made next week.

The team discussed the following to be submitted to the Department to associate designated Administrator by 12pm 9/1/2021.
  • Driver License
  • Administrator's Certificate
  • LIC 503
  • First Aid
  • LIC 501
  • LIC 508
  • LIC 500
  • LIC 308
  • LIC 610

Continued on 809 C.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
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
VISIT DATE: 08/31/2021
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Continued from 809.

The team discussed the following to be submitted to the Department by 12pm 9/1/2021.
  • Plan for food services responsibility
  • Plan for who will be responsible to complete and forward the line list to the Department daily
  • Proof of all payments made
  • Copy of staffing contact
  • Lease agreement

Per the California Code of Regulations, Title 22, no deficiencies observed or cited. Exit interview held with LPA and Licensee via telephone call at 4:30pm. A copy of the report provided via email return receipt. The Licensee is to return a signed copy to LPA by end of day 9/1/2021.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
LIC809 (FAS) - (06/04)
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