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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700803
Report Date: 09/15/2021
Date Signed: 09/15/2021 12:06:54 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:
09/15/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Robbie CantoriaTIME COMPLETED:
12:15 PM
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On 9/15/2021 Regional Manager (RM) Krystall Moore, Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Ashley Boothe, and Program Clinical Consultant (PCC) Paul Portem conducted a Case Management visit via Teams at 10:30am with Temporary Manger(TM) Robbie Cantoria as a result of the facilities licensure status, COVID positive status, ongoing concerns with infection control and staffing.

Current Census per line list is 42, on site is 41 of which 27 positive, 13 cleared and 2 deaths (1 hospice and 1 non hospice). PCR testing results not received due to delay and are expected overnight. Residents in cleared Red Zone will be moved tomorrow and TM stated they will determine a plan to engage cleared residents with activities in group settings to encourage socialization. A calendar will be made for Red Zone and Yellow Zone individual activities to participate in for residents on isolation and quarantine. TM stated plans to confirm PCR testing weekly on Mondays until facility clears with two rounds of testing.

Resident one (R1) had a fall and is being assessed by hospice and Resident two (R2) transported to Hospital, LIC 624 submitted. TM stated Line List in progress will be updated with signs and symptoms, asymptomatic, and skin integrity's by end of day today to be submitted to LPA. TM stated before arrival vitals were not checked in yellow zone and they have implemented vitals checks of all residents and are in process as part of line list update and every shift will be given report on residents conditions.

Screening of visitors and staff by designated staff at all times. Staff are still rapid testing staff upon entry, not sustainable long term, but will continue as long as supplies are in adequate supply. Screening staff twice daily upon entry and exit and upon reentry if they go off site for break.

Continued on 809 C.

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

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
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 2
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: 09/15/2021
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Continued from 809

PPE inventory has been completed, currently working on burn rate and needs include masks and gloves. RM stated shipment will be delivered today. Due to limited supply, PCC provided recommendations for reuse of N95 and TM to follow PCC recommendation for surgical masks in Green Zone. They are currently working to source additional N95's and follow up with LPA to provide update today. Isolation carts are lacking, enough for COVID positive and enough trash cans for all positive rooms but 4 additional carts will need to be purchased for the yellow zone. TM will be sending the RO a map of the facility to LPA today.

TM stated Infection Preventionist (IP) will be on site for not less than 25 hours for two weeks and more as needed. After two weeks IP will be on site as needed. Staff training in-service from 9/14/2021 will be sent to LPA today. The plan for daily in-service this week includes:

  • Donning and Doffing every day this week
  • Cleaning and sanitization
  • Isolation Protocol
  • Hand hygiene

Per the California Code of Regulations, Title 22, Division 6, no deficiencies observed or cited. Exit interview held. A copy of the report provided via email return receipt requested. TM is to return a signed copy to LPA by 9/16/2021.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
LIC809 (FAS) - (06/04)
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