392700803-3-5-2021-27-AS-KHOS-BYZNBB-20210311091851

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700803
Report Date: 03/05/2021
Date Signed: 03/05/2021 11:15:28 AM

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
12/10/2020 and conducted by Evaluator Ruth Wallace

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201210161422

FACILITY NAME:	ROSE PLACE MEMORY CARE		FACILITY NUMBER:	392700803
ADMINISTRATOR:	KNOLL, LORI		FACILITY TYPE:	740
ADDRESS:	1119 ROSEMARIE LANE		TELEPHONE:	(209) 307-6696
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95207
CAPACITY:	68	CENSUS: 40	DATE:	03/05/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Telephone Call - Administrator Lori Knoll Due to Precautions for COVID-19		TIME COMPLETED:	11:25 AM

ALLEGATION(S):

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Facility not administering medications as prescribed.
Centrally stored medication log is not accurate.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Wallace contacted Administrator by phone to deliver findings for a complaint investigation received on 12/10/2020. Findings are being delivered by phone due to current Covid-19 precautionary measures in place.

Allegations: Facility not administering medications as prescribed.
Centrally stored medication log is not accurate.

During the course of the investigation, the LPA did not interview residents due to the fact Administrator submitted a letter stating discrepancies have occurred in the past regarding facility not administering medications as prescribed and centrally stored medication logs inaccurate for residents. A & A Senior Living Management was our management company through 10/31/2020. West Bay Senior Living is our current management company from 11/1/20.

Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021

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-20201210161422

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: 03/05/2021

NARRATIVE

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Continued from 9099 - Page 2

LPA reviewed documents including, but not limited to five resident files; Incident Reports, Medical Records, Physician Reports, Medication Administration Records (MARS), Staff Phone Numbers, and Centrally Stored Medication Logs.

It was determined in the course of the investigation based on the information provided through documentation, the allegations of facility not administering medications as prescribed and centrally stored medication logs inaccurate were substantiated meaning that there was a preponderance of evidence to prove that the allegations occurred as reported. The preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated.
The following deficiencies were cited on 9099-D per Title 22, Division 6 of the California Code of Regulations.
Failure to correct the deficiencies may result in civil penalties.

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, LIC 9099-D, appeal rights, and confidential names list (LIC811) was provided. Administrator is to print out each report, sign it, and send back via email to LPA.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20201210161422

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: 03/05/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/06/2021 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	87465(c)(2) Incidental Medical and Dental Care (c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to submit a plan by 3/6/2021 stating how Staff will receive additional training in medications, charting, and ensure the Health and Welfare of the residents at the facility. Send via email to LPA Ruth Wallace by plan of correction date: 3/6/21 ruth.wallace@dss.ca.gov
	8 9 10 11 12 13 14	Based on LPA’s documentation review of five residents were not given medications as ordered by physician. Licensee did not ensure the health and safety of residents which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 03/12/2021 Section Cited CCR 87506(a)(14)	1 2 3 4 5 6 7	87506(a)(14) Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. (14) Current centrally stored medications as specified in Section 87465, Incidental Medical and Dental Care Services.	1 2 3 4 5 6 7	Licensee agrees to submit a plan by 3/12/2021 stating how Staff will receive additional training in charting centrally stored medication logs and ensure the Health and Welfare of the residents at the facility. Send via email to LPA Ruth Wallace by plan of correction date: 3/12/21 ruth.wallace@dss.ca.gov
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on LPA's documentation of five resident medical records, the centrally stored medication logs were not signed or missing dates of medications for residents. Licensee did not ensure the health and safety of residents in care. This poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021

LIC9099 (FAS) - (06/04)

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