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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600148
Report Date: 04/16/2021
Date Signed: 04/16/2021 04:51:05 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/06/2020 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20200206114143
FACILITY NAME:ROSEGATEFACILITY NUMBER:
015600148
ADMINISTRATOR:MARYCHRIS DAVISFACILITY TYPE:
740
ADDRESS:1345 CLARKE AVENUETELEPHONE:
(510) 483-0150
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:40CENSUS: 19DATE:
04/16/2021
UNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Katie Knox, AdministratorTIME COMPLETED:
03:05 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff not properly trained
Facility not adhering to the terms and conditions of hospice waiver
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 04/16/21 at 2:35PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a tele-visit with administrator to deliver findings of above allegations. Due to COVID-19 shelter in place order, administrator was not physically available to sign this report.

Allegation: Facility staff not properly trained
On 02/11/20, LPA observed staff was unable to produce any documentation of completed and signed training certifications for 2019 during visit. The preponderance of evidence has been met. Therefore, this allegation is substantiated.

Allegation: Facility not adhering to the terms and conditions of hospice waiver
On 02/11/20, LPA observed 7 residents on Hospice Care on review of resident records. Facility's hospice waiver on file was only good for 3 residents. The preponderance of evidence has been met. Therefore, this allegation is substantiated.

Deficiencies cited per Title 22 CA Code of regulations and listed on LIC9099D. Failure to submit plan of correction (POC) on or before POC due date and/or any repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted, appeal rights and a copy of this report provided by email to administrator.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021
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 2
Control Number 15-AS-20200206114143
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ROSEGATE
FACILITY NUMBER: 015600148
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/30/2021
Section Cited
CCR
87412(1)(A)
1
2
3
4
5
6
7
Licensees shall maintain in the personnel records verification of required staff training and orientation. (1) The following staff training and orientation shall be documented: (A) For staff who assist with personal activities of daily living, there shall be documentation of at least ten hours of initial training within the first four weeks of employment, and at least four hours of training annually thereafter in one or more of the content areas as specified in Section 87411(c)(2).
1
2
3
4
5
6
7
Administrator agreed to submit to CCL on or before POC due date proof of staff training for 2019 & 2020.
8
9
10
11
12
13
14
This requirement was not met as evidenced by licensee/administrator unable to produce staff training certifications & documentation during inspection on 02/11/20 which posed a potential health & safety risk to residents in care.
8
9
10
11
12
13
14
Type B
04/16/2021
Section Cited
CCR
87632(a)
1
2
3
4
5
6
7
In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department.
1
2
3
4
5
6
7
Administrator satisfied hospice waiver requirement on 03/04/20 and was approved by CCL to increase hospice waiver from 3 to 8 residents. This deficiency was cleared on 03/04/20.
8
9
10
11
12
13
14
This requirement was not met as evidenced by observation by LPA of 7 residents under hospice care during visit on 02/11/20 when facility's hospice waiver was only good for 3 residents. This posed a potential health & 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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2