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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700803
Report Date: 09/08/2021
Date Signed: 09/08/2021 07:23:57 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: 44DATE:
09/08/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:William LaskeTIME COMPLETED:
07:30 PM
NARRATIVE
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On 9/8/2021 at 2pm, Licensing Program Analyst (LPA) Ashley Boothe, arrived announced to conduct a conduct a Health and Safety visit based on a report of COVID-19 outbreak. LPA met with Designees Staff one (S1), Staff two (S2), and Licensee William Lasky who arrive on site shortly after 2pm to tour the facility with Person one (P1), Infection Preventionist from California Department of Public Health Healthcare Associated Infections Program. P1 coordinated the visit time with Administrator who rescheduled and then did not notify P1 of changed plans to not be in the facility. Newly appointed Administrator was last in the facility on 9/3/2021. Administrator not associated to facility as of today's date and no documents submitted to associated Administrator. Two staff observed not associated in Licensing Information System with criminal record clearance.

As of today 24 residents tested positive and 6 staff tested positive of which 2 staff has cleared and returned to work. Currently all residents are under isolation order due to the outbreak. The team discussed infection control measures and mitigation of COVID-19 in the facility including but not limited to screening, isolation, disinfection, and use off personal protective equipment (PPE). PCR testing was not conducted on 9/6/2021 as scheduled and no attempts to reschedule were made by facility staff. LPA provided technical assistance to coordinate PCR testing for staff through community based sites and rapid test all staff during the visit. The facility is not following Mitigation Plan and infection control practices to mitigate the spread of COVID in the facility.

P1 is to deliver a report to the facility based on observations and discussions during today's visit. The Regional Office will continue to monitor the facility. LPA coordinated PPE from the Regional Office to be delivered.

Continued on 809 C.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 5
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: 09/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/09/2021
Section Cited

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HSC 1569.58(a)(2)Employee Actions: Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the State of California.
This requirement is not met as evidence by:
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Based on observation and interview the licensee did not protect the personal rights of clients in care to receive safe and healthful accommodations and engaged in conduct inimical to the health, welfare, and safety of clients in care, in that the facility has not follow infection control practices which poses an immediate health and safety risk to residents in care.
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Type A
09/09/2021
Section Cited

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87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement is not met as evidence by:
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Based on observation and interview the licensee did not provide staff compentent to provide services necessary to meet residents needs in that the facility has not provided agency staff communication on conditions, medical diagnosis, DNR status, and special diets which 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: 09/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/09/2021
Section Cited

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General Food Service Requirements
(b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidence by:
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Based on observation and interview the licensee did not comply with the section cited above in that R1 was not provided pureed foods for two days time as perscripbed by physican's order which poses an immediate health and safety risk to residents in care.
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Type A
09/09/2021
Section Cited

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Administrator - Qualifications and Duties
(a) ...The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility...there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable ... This requirement is not met as evidency by:
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Based on observation and interview the licensee did not comply with the section cited above in that the administrator appointed to the facility is not available to be at the facility as designated during the announced visit with HAI as confirmed with P1 during COVID outbreak which 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: 09/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/08/2021
Section Cited

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87355(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
This requirement is not met as evidence by:
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Based on observation and interview the licensee did not comply with the section cited above in that two agency staff working in the facility were observed on site and not associated with criminal record clearance transfer requests submitted to the deparment which 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 09/08/2021
NARRATIVE
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LPA and P1's interviews and observations conclude no facility staff have been fit tested for N95 respirator, less than 1 day supply of N95 respirator and gowns on site, communal food and COVID precautions not in place in staff break area, staff providing care to residents without proper donning and doffing of PPE, hand sanitizer not readily accessible to staff in common areas or stored in their pockets, trash cans overflowing with PPE, PPE carts not accessible to staff in common hallways, PPE carts not stocked with essential PPE supplies or inventory practices implemented, no donning, doffing, wear a N95 mask, social distance signs posted in communal areas, no hand washing sign in staff restroom, residents monitored once per shift and pulse oximeter not in working order in Red Zone, no signs to demark isolation start and stop dates, training for proper donning and doffing including return demonstrations not completed, no paper bags for staff to store N95's during break times when N95 supply is not sufficient supply to discard after each use, disinfection practices not frequent to support infection control of high touch surfaces in communal areas where residents access while under isolation order. The Red Zone is staffed with agency staff who have not been provided the necessary communication to provide competent care to residents in that Resident one (R1) did not eat for two days as staff were not provided or made aware of their special diet of pureed foods and Resident two (R2) and Resident three (R3) have not been provided their personal clothing after requests from staff after R2 and R3's room transfer. Residents conditions of hypertension, diabetes, and DNR status not communicated to agency staff. Medical technician requested staff to take vitals and pulse oximeter not in working order to monitor Resident four (R4) residents with increased respiratory symptoms. LPA observed technical assistance provided on site on 8/30/2021 visit not implemented as stated above.

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 Jacob Knoll on site and Licensee over the phone as Licensee was no longer on site and a copy of report was provided to Licensee.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5