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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700803
Report Date: 10/06/2021
Date Signed: 10/06/2021 02:13:23 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: 24DATE:
10/06/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Robert CantoriaTIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced on 10/6/2021 at 11:45am to conduct a case management visit. LPA met with Temporary Manger Robbie Cantoria and stated the purpose of the visit. As of today 29 residents tested positive of which 26 have cleared and 3 deaths. There have been 6 staff tested positive of which 6 cleared. Today's Census is 24.

LPA reviewed Medications Audit completed by Staff one (S1) on 9/23/2021 and verified by Staff two (S2) that documents 14 residents missing medication administrations per physician's order. S2 stated extra supplies of meditations were not centrally stored when medications cart was moved to the locked staff office during COVID outbreak. Based on audit findings, S2 has organized centrally store medications and based on records reviewed documented which medications residents "has" or staff "requested, needs approval, will be delivered, and faxed for next cycle" to ensure medications on site centrally stored to administer to residents per physician's orders. Temporary Manager previously stated the staff are not trained to access and utilize electronic MAR system. On 9/26/2021 the facility transitioned electronic MAR system to paper to ensure accessibility to staff and accuracy of record keeping for all medication administrations.

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 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: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
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: 10/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/07/2021
Section Cited

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Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: This requirement is not met as evidence by:
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Based on observation, interview and record review the facility did not maintain medications administration in that medications centrally stored were not maintained when facility staff move medications storage during COVID outbreak and staff did not have training to utilize electronic MAR resulted in 14 residents missing medications which poses an immediate health and safety risk for 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: 10/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2021
LIC809 (FAS) - (06/04)
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