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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700803
Report Date: 11/02/2021
Date Signed: 11/02/2021 11:19:23 AM

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: 0DATE:
11/02/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:William LaskyTIME COMPLETED:
10:50 AM
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On 11/2/2021 at 10:30am Regional Manager Krystall Moore, Licensing Program Manager Liza King, and Licensing Program Analyst Ashley Boothe conducted an office meeting with Licensee William Lasky and Temporary Manger Robbie Cantoria via Microsoft teams to discuss facility closure. Current census is 0.

The facility is ready for closure as all residents have been relocated. Licensee requested Temporary Manager lock and secure the building on today's date. Licensee requested TM to leave keys with designated Staff One (S1) on today's date. Licensee will coordinate with S1 to secure facility keys after today's date.

Per the California Code of Regulations, Title 22, no deficiencies observed or cited. Exit interview attempted. A copy of the report provided via email return receipt requested. The Licensee is to return a signed copy to LPA by 5pm on 11/2/2021.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
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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