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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700803
Report Date: 10/28/2020
Date Signed: 10/28/2020 06:47:07 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-20200714114315
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: 38DATE:
10/28/2020
UNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Sandeep Singh, Resident Care Director TIME COMPLETED:
06:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident lost a drastic amount of weight
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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.

LPA reviewed Resident1 (R1)'s facility charting notes and hospital records. R1 was admitted to St Joseph's Medical Center on 6/9/2020 and was discharged to the facility same day. Hospital recorded R1's weight at 66kg or 145.5 lbs. R1's hospital records from the visit to San Joaquin General Hospital on 6/20/2020 has R1's weight recorded at 46kg or 101.4 lbs. Between 6/9/2020 and 6/20/2020 R1 lost 44.1 lbs in eleven (11) days. According to Mayo clinic, unexplained weight loss is defined as "If you're losing weight without trying and you're concerned about it, consult your doctor — as a rule of thumb, losing more than 5 percent of your weight within six to 12 months may indicate a problem. If you're an older adult with many or more-serious underlying health issues, even a smaller amount of weight loss may be significant."
...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 3
Control Number 27-AS-20200714114315
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
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
...Continued from LIC 9099...

LPA interviewed Resident Care Director (RCD). RCD stated resident's primary care physician's get notified if a resident has lost a lot of weight. Based on hospital records, R1 lost at least 30 percent of her weight in eleven (11) days (6/09/2020 - 6/20/2020). R1 resided at Rose Place Memory Care between 6/09/2020 and 6/20/2020. Based on R1's hospital records, LPA calculated R1's Body Max Index and calculation showed R1 was overweight on 6/09/2020 and Normal Weight on 6/20/2020. However, facility staff should have notified R1's primary care physician of the drastic weight loss between 6/09/2020 and 6/20/2020.

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

The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in 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 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 3
Control Number 27-AS-20200714114315
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)
Request Denied
Type A
10/29/2020
Section Cited
CCR
87466
1
2
3
4
5
6
7
The licensee shall ensure that residents are regularly observed for changes...When changes such as unusual weight gains or losses...are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician...This requirement has not been met as evidenced by:
1
2
3
4
5
6
7
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.
8
9
10
11
12
13
14
Based on interviews and record review, the licensee did not comply with the regulation cited above by not documenting the unusual weight loss of R1 and not bringing it to the attention of R1's physician 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) -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: 3 of 3