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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600148
Report Date: 05/07/2025
Date Signed: 05/07/2025 04:19:38 PM

Document Has Been Signed on 05/07/2025 04:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ROSEGATEFACILITY NUMBER:
015600148
ADMINISTRATOR/
DIRECTOR:		LEUNG, BELINDAFACILITY TYPE:
740
ADDRESS:1345 CLARKE STREETTELEPHONE:
(510) 483-0150
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 40CENSUS: 36DATE:
05/07/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Jeffrey Tong, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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
On 05/07/2025 at 1:30pm Licensing Program Analysts (LPAs) L. Alexander and Y. Brown arrived unannounced to conduct a Case Management visit. LPAs met with Administrator, Jeffrey Tong.

While LPAs L. Alexander and Y. Brown was conducting a complaint investigation (15-AS-20250430190433) on 05/07/2025. During tour of the facility, LPAs observed that Resident (R) R1's space to get to the bathroom was limited. LPAs brought this issue to S1 and S1 rearranged the room to accommodate better space so that R1 can move around to bathroom if needed.

LPA's observed that there was oxygen in use in R2's room but there was no "Oxygen in Use" signage posted. LPA's observed at 11:54am in shared bedroom for R2 and R3 there was a bottle of Equate ClearLax laxative unlocked.

LPA's observed during file review at 12:05pm that R1's admission agreement was signed 12 days after they were admitted and R1's file was incomplete and missing documents.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Lori Alexander-Washington
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 5
Document Has Been Signed on 05/07/2025 04:19 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 05/07/2025 at 02:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ROSEGATE
FACILITY NUMBER: 015600148

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/21/2025
Section Cited
CCR
87307(a)(2)(A)

1
2
3
4
5
6
7
87307 Personal Accommodations and Services (a) Living accommodations...The facility shall be large enough to provide comfortable living...(2) Resident bedrooms shall...(A) Bedrooms shall be large enough to allow for easy passage between...and any resident assistant devices such as wheelchairs or walkers.the following requirements:

This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator agree to rearrange the furniture in R1's room. During visit LPA's observed the rearrangement on the bedroom and passage way was cleared. Deficiency cleared during visit.
8
9
10
11
12
13
14
Based on observation the licensee did not comply with the section cited above by not having large enough to allow for easy passage between furniture and any resident assistant devices such as wheelchairs or walkers in R1's shared bedroom which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
05/21/2025
Section Cited
CCR87618(b)(3)(B)

1
2
3
4
5
6
7
87618 Oxygen Administration - Gas and Liquid (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (B) "No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas.

This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator agree to post Oxygen in Use signs in appropriate areas and send a photo to CCLD by POC due date. During visit Administrator posted sign. Deficiency cleared.
8
9
10
11
12
13
14
Based on observation the licensee did not comply with the section cited above by not having "Oxygen in Use" signage posted in appropriate area which poses a potential health and safety risk to persons 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/07/2025 04:19 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 05/07/2025 at 02:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ROSEGATE
FACILITY NUMBER: 015600148

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/21/2025
Section Cited
CCR
87465(h)(2)

1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications...
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidence by:

1
2
3
4
5
6
7
Administrator agreed to remove unlocked medications and send a photo to CCLD. In addition, Administrator agreed to conduct an In-Service training with all staff regarding unlocked medications and over-the-counter medications in residents' rooms.
8
9
10
11
12
13
14
Based on observation the licensee did not comply with the section cited above by having unlocked medication, including but not limited to Equate ClearLax Laxative which was unlocked over-the-counter medication in the resident’s room, which poses an immediate health and safety risk to persons in care.
8
9
10
11
12
13
14
Staff training sign-in sheet with synopsis of the training shall be submitted to CCLD by POC due date.

During visit Administrator removed the ClearLax.
Type B
05/21/2025
Section Cited
CCR87507(c)

1
2
3
4
5
6
7
87507 Admission Agreements
(c) Admission agreements shall be signed and dated...no later than seven days following admission.

This requirement is not met as evidence by:

1
2
3
4
5
6
7
Administrator agreed to conduct an In-Service training with admissions team to ensure that admission agreements are signed within 7 days of admission.
8
9
10
11
12
13
14
Based on record review the licensee did not comply with the section cited above by not having R1's admission agreement signed within 7 days of admission to the facility which poses an health, safety and personal rights risk to persons in care.
8
9
10
11
12
13
14
Administrator will send an audit of all admissions within the past 30 days and In-Service sign-in sheet to CCLD by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/07/2025 04:19 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 05/07/2025 at 03:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ROSEGATE
FACILITY NUMBER: 015600148

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/21/2025
Section Cited
CCR
87506(b)(17)

1
2
3
4
5
6
7
87506 (b) Each resident’s record shall contain...(17) Documents and information required by the following:

This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator agreed to reading the regulation by sending self-certification of understanding the regulation. Send updated copies of completed documents for R1 to CCLD by POC due date.
8
9
10
11
12
13
14
Based on record review the licensee did not comply with the section cited above by not having required documents in R1's file including but not limited to Pre-Admission Appraisal which poses a potential health, safety or personal rights risk to persons 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2025


LIC809 (FAS) - (06/04)
Page: 5 of 5