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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 06:00:13 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
08/25/2020 and conducted by Evaluator Diego Escobar
COMPLAINT CONTROL NUMBER: 27-AS-20200825135705
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 not seeking timely medical attention for resident
Resident sustained pressure injury while in care
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 7/30/2020, Resident 1 (R1)’s Home Health Nurse was notified of a skin opening/ wound on R1’s buttocks area while staff conducted a diaper change on R1. The Home Health Nurse, along with multiple facility staff, were unable to rotate Munson in order to properly assess her skin wound. At the end of the visit, the Home Health Nurse verbally instructed facility staff to monitor R1’s's lower back/buttock's skin condition. On 8/4/2020, an Alert Home Health Physician Communication note stated, R1 was confirmed to have a stage three (3) pressure injury on her coccyx. On 08/05/2020, an Alert Home Health Care Nurse found and assessed a stage three (3) pressure injury on R1's coccyx area. R1 was transferred to Golden Living Skilled Nursing Facility on 08/07/2020.
...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-20200825135705
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 Medical Technician (MT1) noticed red peeling skin and dark black colored skin near R1’'s lower back late July 2020. MT1 told CCLD investigator (IB) that she notified her supervisor (S1). S1 told MT1 to call Home Health and inform them of the skin issue. IB asked S1 what he believed caused R1's stage three (3) pressure injury during her stay at Rose Place Memory Care. S1 said R1 was supposed to be repositioned approximately five (5) times per day. However, R1 was only repositioned approximately three (3) times a day. S1 said, "if she was a smaller person, the outcome may have been different." S1 explained that R1 was very heavy set which made it difficult for staff to rotate her when R1 did not assist them.

During IB's interview with MT1, MT1 disclosed that R1 has had bed sores before. Medical Technician (MT2) disclosed to IB that safety checks and repositioning of R1 were unacceptable. S1 disclosed to IB that what R1 went through was unfair and R1 could have been sent out to the hospital earlier. Physician notes confirmed facility staff began the process to transfer R1 to a skilled nursing facility on 8/7/2020, well after R1's pressure injury progressed to a stage three (3) while R1 was still placed in Rose Place Memory Care.

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 deficiencies were 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
08/25/2020 and conducted by Evaluator Diego Escobar
COMPLAINT CONTROL NUMBER: 27-AS-20200825135705

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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9
Staff not notifying resident's authorized representative of resident's relocation
Staff not maintaining resident’s hygiene
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 reviewed Resident 1 (R1)'s facility file. Interviews are contradictory and do not support the allegations stated above. R1's responsible party gave a statement to CCLD where it indicates she was informed verbally of R1's relocation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

Exit interview was conducted with Resident Care Director. Copy of the report sent to Administrator via e-mail with a "read receipt" to verify the LIC 9099 and LIC811 were received. Administrator is to print out the complaint 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-20200825135705
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
87465(g)
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(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). 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 87465(g) at all times.
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Based on interview and record review, the licensee did not comply with the regulation cited above by not seeking timely medical attention for R1 which poses an immediate health and safety risk to residents in care.
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Request Denied
Type A
10/29/2020
Section Cited
CCR
87464(d)
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(d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's 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 87464(d) at all times.
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Based on interview and record review, the licensee did not comply with the regulation cited above by not repositioning R1 as required which led R1 to sustain 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