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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700803
Report Date: 09/10/2021
Date Signed: 09/10/2021 11:02:20 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 CAREFACILITY NUMBER:
392700803
ADMINISTRATOR:KNOLL, LORIFACILITY TYPE:
740
ADDRESS:1119 ROSEMARIE LANETELEPHONE:
(209) 307-6696
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:68CENSUS: 44DATE:
09/10/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:William LaskyTIME COMPLETED:
09:45 AM
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On 9/10/2021 at 9am Regional Manager Krystall Moore, Licensing Program Manager Liza King, Licensing Program Manager Czarrina Camilion-Lee, Audit Manager Jacqueline Juarez and Licensing Program Analyst (LPA) Ashley Boothe conducted an office meeting with Licensee William Lasky via Microsoft teams to discuss facility operations, COVID-19 outbreak, and plans of corrections due to the Department on 9/9/2021 from on site inspection on 9/8/2021. Current census is 43.

Plans of Corrections submitted for review did not provide timely response to ensure the immediate health, safety, and personal rights risks of resident's in care during the COVID outbreak. POC's not cleared as of today's date. The Licensee agreed to review and resubmit POC's by 5pm on 9/10/2021.

The Licensee has enlisted a consultant to be designated to the facility, Person One (P1). The Licensee has agreed to submit Designation Forms, LIC 308, for qualified and designated a staff in charge to be on site daily including contact information for all designees to be reached in case of emergency by 5pm on 9/10/2021.

The Licensee agrees to submit by 12pm every day moving forward a staff schedule of all staff working and that identifies which designated staff is in charge on site at the facility.

The Licensee has not associated staff to the facility including Administrator, P1, and agency staff working in the facility. The Licensee agrees to submit documents to the Department to associate all staff as they do not have an active Guardian account set up.

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 9/10/2021.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021
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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