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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700803
Report Date: 09/03/2021
Date Signed: 09/03/2021 04:55:52 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:
09/03/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
04:48 PM
MET WITH:William LaskyTIME COMPLETED:
05:00 PM
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On 9/3/2021 at 4:48pm Licensing Program Analyst (LPA) Ashley Boothe conducted an office meeting with Licensee William Lasky via telephone call to discuss facility operations and COVID-19 outbreak. Current census is 44.

As of today, 19 residents and 5 staff tested positive for COVID-19. The Regional Office is monitoring the facility daily for COVID-19 outbreak.

On today’s date the Administrator of record delivered written notification of resignation to Licensee effective today’s date. The Department has requested a plan to ensure oversight to facility operations during the COVID-19 outbreak. Currently the Licensee has requested to designate Staff one (S1) to the facility who does not hold current administrative certificate, renewal pending, or Infection Preventionist Certification. The LIC 500, staffing report submitted on today’s date does record compliance with California Code of Regulations Title 22 87405(a). Due to the immediate resignation of the Administrator of record the Department is providing the Licensee one week to designate and associate staff that meet the qualifications listed below by 5pm on 9/10/2021.
  • An qualified and currently certified Administrator to be on site at the facility minimum 40 hours per week.
  • An Infection Preventionist Certified through CDC or other authorized vendor be on site at the facility minimum 20 hours and available on call as necessary to provide oversight to the COVID-19 outbreak.

Per the California Code of Regulations, Title 22, no deficiencies observed or cited. Exit interview held. A copy of the report provided via email return receipt requested. The Licensee is to return a signed copy to LPA by 5pm on 9/7/2021.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
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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