392700803-9-11-2021-27-AS-ABOE-C6S4TF-20210911192303

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700803
Report Date: 09/11/2021
Date Signed: 09/11/2021 07:23:15 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 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:	09/11/2021
TYPE OF VISIT:	Case Management - Health Checks	UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Jakob Knoll		TIME COMPLETED:	07:45 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	Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced on 9/11/2021 at 4:30pm to conduct a health and safety check on the residents and clear POC's from 9/8/2021 visit submitted to the Department on 9/10/2021 via email. LPA met with Designee Jakob Knoll, Medication Technician, and stated the purpose of the visit. As of today 26 residents tested positive and 6 staff tested positive of which 2 staff has cleared and returned to work and one resident death. Currently all residents are under isolation order due to the outbreak. Resident one (R1) passed away and not reported to the Department. Jacob stated he would submit Death Report today. Staff one (S1), Staff two (S2), Staff three (S3), and Staff four (S4) not associated to the facility. LPA and Jacob toured and inspected the physical plant to ensure there are no safety hazards to residents. Observed Red Zone floors sticky and soiled. 4 of 4 agency staff stated they had not seen housekeeping in the area and S1 and S2 stated they do the best they can but sometimes it is hard because there are only two of them to keep clean. Observed soiled linen stored in open trash can without a lid in Red Zone hallway, Red Zone staff break room with communal foods, trash cans over flowing with PPE, and no COVID universal precautions signs posted. Observed 4 isolation carts not stocked with PPE supplies and PPE not easily accessible in one closet in the Red Zone. No additional hand sanitizer was made available to staff and not kept on their persons. Observed resident records and 7 of 43 vitals checks not documented. S1 and S3 stated they take vitals twice per shift. Jacob state he would make a document today to record vitals every 4 hours. 2 of 4 agency staff in the Red Zone were unaware of residents conditions including special diet, diabetes, and DNR status. Observed list for agency staff for special diets but not for DNR status or medical conditions, Jacob stated he would make it today. Observed in-service training log- infection control for today to include staff but 4 of 4 agency staff not provided the training. Jacob stated training included donning and doffing and hand hygiene. No additional COVID signs posted in hallways including donning and doffing, social distancing, wearing a mask. Observed staff provide care to Yellow Zone residents without donning PPE. Observed Staff five (S5) wearing a surgical mask in Yellow Zone, who stated "they were not working in the COVID unit" and were unaware of Yellow Zone persons under investigation status. Continued on 809. C

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2021

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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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: 09/11/2021

NARRATIVE

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LPA observed 3 staff donn face shields not worn upon LPA's arrival, Jacob requested on the radio all staff wear a shield. Observed there are 8 caregivers, 0 Housekeeper, 1 Cook, and 1 Medication Technician working during this visit. 4 agency staff working in the Red Zone and 4 regular staff working in the Yellow Zone. The facility was cited for not associating agency staff twice. The most recent citation was on 9/10/21. The plan of correction is due 9/13/21. Due to todays findings that there are 4 agency staff working without being associated, the facility will not be cited today to allow time to clear the previous citations and to associate any new persons including those coming to work from any agency. Observed 2 day perishables and 7 day non-perishables food items. LPA observed dinner being prepared which included chicken, green beans, rice and juice and 7 pureed dinners prepared.

Deficiency cited under Health and Safety Code 1569.58(a)(2) during inspection on 9/8/2021. Licensee has not complied with the terms of the POC by approved extension of POC due date in that residents are not monitored for COVID symptoms, signs not posted, staff not wearing PPE effectively, disinfection of Red Zone not maintained, and PPE not readily available to staff in stocked isolation carts. Deficiency cited under Title 22 87411(a) during inspection on 9/8/2021. Licensee has not complied with the terms of the POC by approved extension of POC due date in that agency care staff have not been provided in service and documentation on residents care plans. Failure to Correct Civil Penalties assessed on today's date and LIC421FC(s) provided.

Deficiency cited under Title 22 87555(b)(7) during inspection on 9/8/2021. The Licensee has not complied with the terms of the POC by approved extension of POC due date in that agency care staff have been provided a list for of residents special diets. Deficiency cited under Title 22 87405(a) during inspection on 9/8/2021. The Licensee has complied with the terms of the POC by approved extension of POC due date in that the Licensee has submitted an LIC 308 to designate a staff when certified Administrator is not available to be on site. POC letter(s) provided on today's date.

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 with designated staff Jakob Knoll and a copy of report was provided.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2021

LIC809 (FAS) - (06/04)

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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: 09/11/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/13/2021 Section Cited	1 2 3 4 5 6 7	Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by:
	8 9 10 11 12 13 14	Based on observation and interview Housekeeping staff have not maintained a sanitary facility. The Red Zone was observed with sticky and soiled floors and soiled linen was observed in hallyway without a lid cover which poses an immediate 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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2021

LIC809 (FAS) - (06/04)

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