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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700803
Report Date: 10/27/2021
Date Signed: 10/27/2021 01:10:16 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/27/2021 and conducted by Evaluator Ashley Boothe
COMPLAINT CONTROL NUMBER: 27-AS-20210827152841
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: 11DATE:
10/27/2021
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Robbie CantoriaTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility not solvent
INVESTIGATION FINDINGS:
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On 10/27/2021 at10:15am, Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conclude complaint investigation with the following allegations: Facility not solvent. LPA met with Temporary Manager and explained the purpose of today’s visit. LPA was allowed entry into the facility, current census is 11.

During the course of the investigation LPA conducted on site inspection, reviewed records, and conducted interviews. The facility has been found to not be financially solvent. Food delivery vendors, ultility company, communication services, paper and personal care suppler, electronic medication administration record vendor, training vendor, contractors, and staff reimbursments of personal monies not paid with outstanding balances due of more than $60,000. Staffing agencies not paid with ourstanding balance dues of more than $79,000. Refunds to residents responsible parties not paid with ourstanding balances due of more than $11,000. Facility staff reported no communication with licensee and no payments made on past due amounts.
Facility operations impacted from lack of payments made in that food delivery vendors refused services.

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

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20210827152841
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/27/2021
NARRATIVE
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Based on information obtained the aforementioned allegation is SUBSTANTIATED. A finding that the complaint is substantiated means the preponderance of evidence standard has been met, therefore the allegation(s) is found to be substantiated.

Per California Code of Regulations (CCRs) - Title 22, Division 6, 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: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20210827152841
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/28/2021
Section Cited
CCR
87213
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Finances The licensee shall have a financial plan that conforms to the requirements...that assures sufficient resources to meet operating costs for care of residents; shall maintain adequate financial records...
This requirement is not met as evidence by:
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The licensee has refused communcations with facility designee Staff One (S1). POC corrected at time of visit as facility is ceasing operations.
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Based on observation, interview, and record review the Licensee hoe not maintain sufficient resouces to meet operating costs which poses an 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: 10/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3