<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700803
Report Date: 10/27/2021
Date Signed: 10/27/2021 01:20:35 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
10/05/2021 and conducted by Evaluator Ashley Boothe
COMPLAINT CONTROL NUMBER: 27-AS-20211005162853
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):
1
2
3
4
5
6
7
8
9
Resident lost 20lbs from July 2021
Resident was not provided medications as ordered
Family was not notified of change in condition
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/27/2021 at 10:15am, Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conclude complaint investigation with the following allegations: Resident lost 20lbs from July 2021, Resident was not provided medications as ordered, and Family was not notified of change in condition. 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, conducted interviews, and conducted a collateral visit on 10/21/2021 to a licensed care facility to review records and interview staff.

The facility did not record residents' weights in August or September 2021. R1 was observed to lose 20 lbs from July 2021 facility weight record to September 2021 hospital visit. Facility case notes do not document and interviews concluded staff did not observe R1's weight loss or notification to responsible party for change in condition.
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 4
Control Number 27-AS-20211005162853
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
R1 observed to missed 15 medication administrations per physician's orders facility during COVID outbreak at the facility. R1's centrally stored logs date filled Medication (M1) in April 2021 date stated blank, observed M1 on R1's medication transfer release not administered as physician's order in April 2021.

R1 reported COVID positive. In September 2021 staff one (S1) documented in case notes R1 "no symptoms of virus, staff will continue to monitor" and case notes one week later R1 "has only been eating 15% of meals when staff encourage" No changes of condition were documented to be reported to R1's responsible party.

Based on information obtained the aforementioned allegations are 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 4
Control Number 27-AS-20211005162853
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
87466
1
2
3
4
5
6
7
Observation of the Resident ... When changes such as unusual weight gains or losses..., the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
This requirement is not met as evidence by:
1
2
3
4
5
6
7
POC cleared prior to todays date in that Temporary Manager weighed all residents and notified responsible parties on 9/30/2021. POC cleared prior to today's date.
8
9
10
11
12
13
14
Based on observation and interview the licensee did not ensure R1's responsible party was notified of unusal weightloss of 20lbs which poses an immediate health and saftey risk to residents in care.

8
9
10
11
12
13
14
Type A
10/28/2021
Section Cited
CCR
87465(a)(5)
1
2
3
4
5
6
7
Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. (5) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidence by:
1
2
3
4
5
6
7
POC cleared prior to todays date in that Temporary Manager audited all medications to ensure all residents Centrally Stored Medications linear with MARs and inservice training for all medical technicians.
***Civil Penalty assessed on LIC421FC for defeciency last cited on 3/16/2021***
8
9
10
11
12
13
14
Based on observation and interview the licensee did not ensure R1's prescription for M1 logged on centrally stored as administered per physician's orders and 15 missed adminsitrations during September 2021 which poses an immediate health and safety risk to residents in care.

8
9
10
11
12
13
14
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 4
Control Number 27-AS-20211005162853
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
874765(a)(1)
1
2
3
4
5
6
7
Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility.(1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidence by:
1
2
3
4
5
6
7
POC cleared prior to todays date in that Tempory Manager ensured residents were reassed by physican. POC cleared prior to today's date.
8
9
10
11
12
13
14
Based on observation, interview, and record review the licensee did not ensure medical care plan for R1 during weight loss of 20 pounds from July 2021 to September 2021 which poses an immediate 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 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: 4 of 4