392700803-10-23-2020-27-AS-LKIG-BUUS2N-20201029132948

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700803
Report Date: 10/23/2020
Date Signed: 10/23/2020 04:04:17 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
05/14/2020 and conducted by Evaluator Diego Escobar

COMPLAINT CONTROL NUMBER: 27-AS-20200514144734

FACILITY NAME:	ROSE PLACE MEMORY CARE		FACILITY NUMBER:	392700803
ADMINISTRATOR:	GREWAL, KAMAL		FACILITY TYPE:	740
ADDRESS:	1119 ROSEMARIE LANE		TELEPHONE:	(415) 710-7538
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95207
CAPACITY:	68	CENSUS: 38	DATE:	10/23/2020
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Lori Knoll, Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

1
2
3
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5
6
7
8
9

Facility failed to control spread of lice
Responsible party not notified of resident injury
Resident's diet not being followed
Resident has infection due to lack of care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Diego Escobar made a subsequent investigation televisit on 10/23/2020 to deliver the allegation findings. LPA spoke to Lori Knoll, Administrator, and explained the purpose of the call.

LPA reviewed facility files of Resident 1 and 2 (R1, R2), and interviewed Staff 1 and 2 (S1, S2). LPA reviewed medical records, charting notes, medication administartion records. Interviews and documents reviewed do not support the allegations listed above.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated.

Exit interview was conducted with Administrator. Copy of the report sent to Administrator via e-mail with a "read receipt" to verify the LIC 9099 was received. Lori is to print out each report, and fax a signed copy to LPA at 916-263-4744.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Diego Escobar	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2020

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

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
05/14/2020 and conducted by Evaluator Diego Escobar

COMPLAINT CONTROL NUMBER: 27-AS-20200514144734

FACILITY NAME:	ROSE PLACE MEMORY CARE		FACILITY NUMBER:	392700803
ADMINISTRATOR:	GREWAL, KAMAL		FACILITY TYPE:	740
ADDRESS:	1119 ROSEMARIE LANE		TELEPHONE:	(415) 710-7538
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95207
CAPACITY:	68	CENSUS: 38	DATE:	10/23/2020
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Lori Knoll, Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Medication not given as instructed

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Diego Escobar made a subsequent investigation televisit on 10/23/2020 to deliver the allegation findings. LPA spoke to Lori Knoll, Administrator, and explained the purpose of the call.

LPA reviewed facility files of Resident 1 and 2 (R1, R2), and interviewed Staff 1 and 2 (S1, S2). LPA reviewed medical records, charting notes, medication administration records. R2 did not receive Medication 1 (M1) on 5/20/2020. Medical technician notes on 5/20/2020 state "no needed to give." However, Physician orders indicate R2 was supposed to take M1 based on the test strip reading on 5/20/2020 at 7:00AM. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Appeal rights were provided. Exit interview conducted with Administrator. Copy of the report sent to Administrator via e-mail with a "read receipt" to verify the complaint report and appeal rights were received. Administrator is to print out the complaint report and fax signed copies to LPA at 916-263-4744.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Diego Escobar	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20200514144734

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: 10/23/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/28/2020 Section Cited CCR 87464(f)(4)	1 2 3 4 5 6 7	(f) Basic services shall at a minimum include:(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as...assistance with taking prescribed medications...This requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to submit a plan of correction to LPA by 10/28/2020 on how residents will be assisted with taking their prescribed medications. Additionally, Licensee agrees to conduct a medication review in-service with staff.
	8 9 10 11 12 13 14	Based on record review the licensee did not comply with the regulation cited above by not assisting R2 with his prescribed medication (M1) on 5/20/2020, which poses an potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 King	TELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Diego Escobar	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2020

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2020

LIC9099 (FAS) - (06/04)

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