392700803-10-16-2020-27-AS-LKIG-BUML76-20201022082948

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700803
Report Date: 10/16/2020
Date Signed: 10/16/2020 01:46:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/06/2020 and conducted by Evaluator Diego Escobar

COMPLAINT CONTROL NUMBER: 27-AS-20200706103706

FACILITY NAME:	ROSE PLACE MEMORY CARE		FACILITY NUMBER:	392700803
ADMINISTRATOR:	GREWAL, KAMAL		FACILITY TYPE:	740
ADDRESS:	1119 ROSEMARIE LANE		TELEPHONE:	(415) 710-7538
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95207
CAPACITY:	68	CENSUS: 39	DATE:	10/16/2020
		UNANNOUNCED	TIME BEGAN:	01:21 PM
MET WITH:	Lori Knoll, Administrator		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Facility staff did not notify authorized representative of resident's change in condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Diego Escobar made a subsequent complaint investigation televisit on 10/16/2020. LPA spoke to Lori Knoll, Administrator, and explained the purpose of the visit.

LPA reviewed facility charting notes which indicate a voicemail was left for Resident 1 (R1)'s responsible party on 7/1/2020 with regards to R1's change of condition and admittance to the hospital. Charting notes also indicate R1's primary care physician was also notified via fax.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated.

Exit interview was conducted with Administrator. Copy of the report sent to Administrator via e-mail with a "read receipt" to verify the LIC 9099 and LIC811 werereceived. Administrator is to print out each report, and fax a signed copy to LPA at 916-263-4744.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Diego Escobar	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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