392700803-11-20-2020-27-AS-KHOS-BVVLSA-20201201080026

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700803
Report Date: 11/20/2020
Date Signed: 11/20/2020 04:52:57 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
06/17/2020 and conducted by Evaluator Diego Escobar

COMPLAINT CONTROL NUMBER: 27-AS-20200617144345

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: 36	DATE:	11/20/2020
		UNANNOUNCED	TIME BEGAN:	04:25 PM
MET WITH:	Lori Knoll, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not properly tending to resident's pressure injury.
Resident sustained multiple falls while in care.
Resident's care needs are not being met.

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 11/20/2020 to deliver the allegation findings. LPA spoke to Lori Knoll, Administrator, and explained the purpose of the call.

LPA reviewed facility file of Resident 1 (R1) and interviewed staff 1 (S1). On 6/11/2020 facility staff noticed a "skin issue" on R1 and the primary care physician was notified the same day. Staff continued to reposition R1. Staff called R1's doctor again on 6/13/2020 and again on 6/15/2020 but no further instructions were given. R1 was sent to St. Joseph's Medical Center on 6/16/2020 for further evaluation. LPA further reviewed R1's medical records and charting notes. Interviews conducted 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: 11/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2020

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 1