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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700803
Report Date: 11/20/2020
Date Signed: 11/20/2020 04:49:32 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
07/14/2020 and conducted by Evaluator Diego Escobar
COMPLAINT CONTROL NUMBER: 27-AS-20200714135515
FACILITY NAME:ROSE PLACE MEMORY CAREFACILITY NUMBER:
392700803
ADMINISTRATOR:GREWAL, KAMALFACILITY TYPE:
740
ADDRESS:1119 ROSEMARIE LANETELEPHONE:
(415) 710-7538
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:68CENSUS: 36DATE:
11/20/2020
UNANNOUNCEDTIME BEGAN:
04:25 PM
MET WITH:Lori Knoll, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff failed to properly maintain resident's bathroom while in care
Staff failed to ensure resident's oxygen needs were met while in care
Staff failed to provide resident with appropriate linens
Staff did not meet resident's dental needs while in care
Staff failed to provide a comfortable temperature for resident
Staff failed to ensure resident's sanitary needs are met while in 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 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) and staff 2 (S2). LPA toured R1's room and reviewed R1's medical records, care plan and charting notes. Interviews conducted and documents reviewed contradict the allegation details.
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. Administrator 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 KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Diego EscobarTELEPHONE: (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)
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