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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700803
Report Date: 10/28/2020
Date Signed: 10/28/2020 06:36:52 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
07/21/2020 and conducted by Evaluator Diego Escobar
COMPLAINT CONTROL NUMBER: 27-AS-20200721145026
FACILITY NAME:ROSE PLACE MEMORY CAREFACILITY NUMBER:
392700803
ADMINISTRATOR:GREWAL, KAMALFACILITY TYPE:
740
ADDRESS:1119 ROSEMARIE LANETELEPHONE:
(209) 307-6696
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:68CENSUS: 38DATE:
10/28/2020
UNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Sandeep Singh, Resident Care DirectorTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Resident sustained a stage 4 pressure injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Diego Escobar made a subsequent complaint investigation televisit on 10/28/2020. LPA spoke to Sandeep Singh, Resident Care Director, and explained the purpose of the visit.

On 07/01/2020, facility staff sent Resident 1 (R1) to St. Joseph's Medical Center (SJMC) regarding a pressure injury which was initially discovered by the facility on 06/30/2020. On 07/02/2020, a SJMC wound care note indicates R1 was admitted with an unstageable right buttock pressure injury. Surrounding skin was a stage 3 full thickness pressure injury on the sacrum. SJMC medical records indicate the injury had a red granular wound bed. Facility residents ( R2, R3, R4) were interviewed, and no serious disclosures of mistreatment were made regarding R1 or other residents. Facility staff reported that prior to 06/30/2020, facility staff did not observe any unusual skin conditions on R1's buttocks. Charting notes do not document any unusual skin conditions on R1.
...CONTINUES ON LIC 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Diego EscobarTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020
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 4
Control Number 27-AS-20200721145026
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: 10/28/2020
NARRATIVE
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...CONTINUED FROM LIC 9099...

Facility staff reported that they assisted R1 with bathing, dressing, and toileting. R1 was bathed two or three times a week, she was dressed multiple times a day as needed, and her adult diapers were checked at least every two hours to make sure they were dry. Facility staff also assisted R1 if she chose to use the toilet. Since R1 was able to ambulate independent of staff assistance or assistive devices she did not need to be repositioned. Facility staff denied observing unusual skin conditions (redness, open areas, skin tears etc.) while providing routine care. R1 was not on home health or hospice while residing at the facility.

This investigation concludes that facility staff failed to observe changes in skin condition on R1’s buttocks while providing her with routine care (dressing, showering, toileting) and they failed to seek appropriate care in a timely manner. Thus, resulting in a stage 3 and unstageable pressure injury to R1's buttocks.

Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated.

Administrator was informed that a civil penalty assessment based on Health and Safety Code § 1548 is currently under review and may be assessed on a later date, as a result of R1 sustaining a pressure injury while in care of the facility. Once civil penalty assessment has been determined, LPA will return on a future date to assess the civil penalty.

The following deficiency was observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. A civil penalty in the amount of $500 is being issued on today's visit due to the violation resulting in R1 sustaining injuries Failure to correct the deficiency may result in additional civil penalties. Appeal rights were provided. Exit interview conducted with Sandeep. Copy of the report sent to Administrator and Sandeep via e-mail with a "read receipt" to verify the LIC 9009, LIC 9099-C, LIC 9099-D, LIC 811, Civil Penalty and appeal rights were received. Administrator is to print out the report and fax signed copies to LPA at 916-263-4744.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Diego EscobarTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
07/21/2020 and conducted by Evaluator Diego Escobar
COMPLAINT CONTROL NUMBER: 27-AS-20200721145026

FACILITY NAME:ROSE PLACE MEMORY CAREFACILITY NUMBER:
392700803
ADMINISTRATOR:GREWAL, KAMALFACILITY TYPE:
740
ADDRESS:1119 ROSEMARIE LANETELEPHONE:
(209) 307-6696
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY:68CENSUS: 38DATE:
10/28/2020
UNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Sandeep Singh, Resident Care DirectorTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff did not inform authorized representative the change of health conditions of resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Diego Escobar made a subsequent complaint investigation televisit on 10/28/2020. LPA spoke to Sandeep Singh, Resident Care Director, and explained the purpose of the visit.

The department conducted interviews with facility staff and Resident 1 (R1)'s family. Interview statements are contradictory and do not support the allegation stated 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 Sandeep. Copy of the report sent to Administrator via e-mail with a "read receipt" to verify the LIC 9099 and LIC 811 were 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: 10/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20200721145026
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: 10/28/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
10/29/2020
Section Cited
CCR
87466
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The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs...This requirement has not been met as evidenced by:
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Licensee agrees to submit a plan of correction to LPA by 10/29/2020 on how the facility will be in compliance with regulation 87466 at all times.
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Based on interviews and record review, the licensee did not comply with the regulation cited above by failing to regularly observe R1 which resulted in R1 sustaining a pressure injury which poses an immediate health and safety 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) -26-4752
LICENSING EVALUATOR NAME: Diego EscobarTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 4