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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 09:08:10 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: 43DATE:
09/10/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
07:00 PM
MET WITH:Jakob KnollTIME COMPLETED:
09:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 9/10/21 at 7:00pm to conduct a health and safety check on the residents. LPA met with Jakob Knoll, Resident Care Coordinator and stated the purpose of the visit.

LPA and Jakob Knoll toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents.

The facility is licensed for a capacity of 68 non ambulatory of which 6 may be bedridden. Facility has a Hospice Waiver for 15. Currently, there are 10 residents receiving hospice services at this time.

LPA observed there are 3 caregivers, 1 Housekeeper and 1 Medication Technician working during this visit. 1 caregiver is from a staffing agency that is not associated to the facility.

LPA observed 2 day perishables and 7 day non-perishables food items. LPA observed juice, water, granola bars and potato chips prepared for resident to have for a snack.

The hot water measured at 105.5*F which is within the required range of 105-120*F.

LPA observed the centrally stored medications area to be locked and inaccessible to residents.

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. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. Jakob Knoll was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held. A copy of todays’ report provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
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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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: 09/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/13/2021
Section Cited

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Criminal Record Clearance
Violation of Section 87355(e) shall result in an immediate assessment of civil penalties of one hundred dollars ($100) per violation per day for a maximum of five (5) days by the department. (1) Subsequent violations within a twelve (12) month period will result in a civil penalty of one hundred ($100) per violation per day for a maximum of thirty (30) days.
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This requirement is not met as evidenced by: The person was working during this visit and facility was previously cited for this person.
Based on Staff providing the name of all the staff working during this visit.
This poses an immediate health and safety risk to residents in care.

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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2021
LIC809 (FAS) - (06/04)
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