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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700803
Report Date: 09/13/2021
Date Signed: 09/13/2021 07:36:12 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: 42DATE:
09/13/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Alicia CarranzaTIME COMPLETED:
07:50 PM
NARRATIVE
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Regional Manager (RM) Krystall Moore, Licensing Program Manager (LPM) Liza King, and Licensing Program Analyst (LPA) Ashley Boothe and Kathryn Thomas (Ombudsman) arrived for the purpose of delivering a Temporary Suspension Order (TSO) on today's date of 09/13/2021 that is effective as to today's date. The aforementioned individuals met with Alicia Carranza Designee. RM Moore reviewed the TSO paperwork Licensee William Laskey over the phone and advised that a copy will be certified mailed. RM Moore provided the Appeal/Notice of Defense process and advised that the facility is unable to accept residents at this time due to the TSO. The Licensee was advised that the Department has implemented a Temporary Manager as of today's date who will assume all operations of the facility. A copy of the TSO paperwork left with designee on today's visit.

RM Moore, LPA Boothe, Ombudsman, Designee, and Temporary Manager toured the facility. There are currently 42 residents in care. As of today there are 26 residents tested positive for COVID of which 2 have passed. A number of residents have cleared through Local Health Department and will move out of isolation tomorrow.

The team observed in the Red Zone soiled floors in resident rooms but hallway cleaned and Designee stated they were unsure who mopped, room 10 and 11 with no bed linens, rattling air conditioner making a loud noise in room 15 and broken lock on fire door. Observed residents in room 11 and room 18 with no pants on, multiple residents with no shoes and dirty feet.

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

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
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 4
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: 09/13/2021
NARRATIVE
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Continued from 809.

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 signs not posted, staff not wearing PPE effectively, disinfection of Red Zone not maintained, trash cans to doff PPE not located throughout the facility, isolation carts and hand sanitizer not readily available to staff in that no hand sanitizer was available at exit of Red Zone. 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. Deficiency cited under Title 22 87303(a) during inspection on 9/11/2021. Licensee has not complied with the terms of the POC by approved extension of POC due date in that the Red Zone soiled floors. Failure to Correct Civil Penalties assessed on today's date and LIC421FC(s) provided.

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 Alicia Carranza and a copy of report was provided.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 09/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2021
Section Cited

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Personal Accommodations and Services
(a) Living accommodations.(3) Equipment and supplies necessary... linen...quantity shall be sufficient. This requirement not met as evidence by:
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Based on ovservation and interview the licensee did not comply with the section cited above in that room 10 and 11 had no bed linens which poses a potential 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: 09/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 09/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/14/2021
Section Cited

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Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: This requirement not met as evidence by:
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Based on observation the licensee did not comply with the section cited above in that residents in room 11 and room 18 with no pants on, multiple residents with no shoes and dirty feet which poses a immediate health, safety, and personal rights 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: 09/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4