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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700803
Report Date: 09/12/2021
Date Signed: 09/12/2021 04:30:22 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:
09/12/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Savanah RiosTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived at this facility unannounced to conduct a health and safety visit. LPA met with Savanah Rios and explained the purpose of the visit.

LPA toured the facility with Jessica Jones and inspected the physical plant to ensure there are no safety hazards to residents. There are currently 25 residents residing in the red zone, and 18 residents residing in the yellow zone. There are 4 staff currently working on the non-positive side and 4 staff working on the positive side from a care staffing agency.

LPA inspected the facility kitchen and medication. LPA also toured the outside and observed the main red zone entry door. LPA observed the main front entry point. The facility's main entry doors has PPE postings.

The facility has requested additional face shields, individual hand sanitizers to keep on their person, and disinfecting wipes.

An exit interview was conducted, and a copy of this report was emailed to Sylvia Cruz due to Covid-19 precautionary measures.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2021
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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