392700803-9-12-2021-27-AS-AMAZ-C6SNMC-20210912103454

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700803
Report Date: 09/12/2021
Date Signed: 09/12/2021 10:35:08 AM

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 CARE		FACILITY NUMBER:	392700803
ADMINISTRATOR:	KNOLL, LORI		FACILITY TYPE:	740
ADDRESS:	1119 ROSEMARIE LANE		TELEPHONE:	(209) 307-6696
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95207
CAPACITY:	68	CENSUS: 43	DATE:	09/12/2021
TYPE OF VISIT:	Case Management - Health Checks	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Sylvia Cruz		TIME COMPLETED:	10:30 AM

NARRATIVE

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Licensing Program Analyst (LPA) Avelina Martinez arrived at this facility unannounced to conduct a health and safety visit on 09/12/2021. LPA met with Sylvia Cruz and explained the purpose of the visit.

LPA Martinez toured the facility with Sylvia Cruz on 09/12/2021, and inspected the physical plant to ensure there are no safety hazards to residents. There are currently 25 residents residing in the red zone, and 18 residents residing in the yellow zone. There are 8 staff currently working, in addition, this facility is working with a care staffing agency.

LPA Martinez inspected the facility medication cart and medication. The AM medication pass was completed. LPA also toured the outside and observed the main red zone entry door. LPA observed the main front entry point. The facility's main entry doors has PPE postings. The facility provides rapid testing before entering the facility and conducts screening and temperature checks. The facility has trash cans with lids throughout the facility. The outside main entry point has a trash can with a lid for doffing PPE.

An exit interview was conducted, and a copy of this report was emailed to Sylvia Cruz due to Covid-19 precautionary measures.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2021

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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