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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600148
Report Date: 09/07/2022
Date Signed: 09/07/2022 04:40:20 PM

Substantiated


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
08/29/2022 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20220829164946
FACILITY NAME:ROSEGATEFACILITY NUMBER:
015600148
ADMINISTRATOR:LEUNG, BELINDAFACILITY TYPE:
740
ADDRESS:1345 CLARKE STREETTELEPHONE:
(510) 483-0150
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:40CENSUS: 17DATE:
09/07/2022
UNANNOUNCEDTIME BEGAN:
02:42 PM
MET WITH:Jeffrey Tong, Administrator TIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Staff left disinfectant cleaning supplies accessible to residents.
INVESTIGATION FINDINGS:
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On 09/07/22 at 2:30PM, Licensing Program Analyst (LPA) K Nguyen arrived unannounced to conduct complaint investigation for the above allegations. LPA was greeting by Sui Wah Cheng (Sandy) Site Supervisor and explained the purpose of the visit. LPA toured the facility with Sandy; later Jeffrey Tong Administrator arrived at 3PM.

During the toured LPA observed the following:

At 2:45PM LPA observed cleaning supply cart stored in the backyard easy assessble for resident.

During the complaint investigation, LPA toured facility, collected documents, and interviewed S1. Based on observation, LPA observed unlocked cleaning supply cart are being stored in the backyard accessible to residents. S1 stated that her desk is located near the exit to the backyard. Resident can not walk pass her desk without her knowning. However, LPA observed that residents walked pass her desk, and have access to use the exit door to enter the backyard without staff’s supervision.

Report continue on LIC 9099C...



Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
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 15-AS-20220829164946
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: 09/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/08/2022
Section Cited
CCR
87705(f)(2)
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87705(f)(2) Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:

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By POC date 9/8/2022, Administrator will lock cleaning supplies and submit a photo to CCLD.
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Based on observation, Licensee did not comply with the regulations cited above. LPA observed unlocked cleaning supply cart are being stored in the backyard accessible to residents which poses an immediate health and safety risk to persons 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: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20220829164946
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
VISIT DATE: 09/07/2022
NARRATIVE
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Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3