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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600148
Report Date: 10/31/2025
Date Signed: 10/31/2025 03:50:47 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
10/27/2025 and conducted by Evaluator Yasamin Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20251027194916
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: 38DATE:
10/31/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Irene Deleon, Facility Manager TIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff did not provide adequate supervision resulting in resident wandering away from facility.

Staff did not inform resident's responsible party of incident.
INVESTIGATION FINDINGS:
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On 10/31/2025 at 9:30 AM, Licensing Program Analysts (LPAs) Y. Brown and L. Fontanilla arrived unannounced to conduct investigation/ deliver findings for the above allegations. LPAs met with Irene Deleon, House Manager and explained the purpose of the visit. Backup Administrator, Jeffrey Tong arrived to the facility around 11 am.

During investigation, LPAs reviewed and obtained the following documents from ADM – Residents’ roster, Personnel Record (LIC500) / Work Schedules and resident incident reports.

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
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 4
Control Number 15-AS-20251027194916
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ROSEGATE
FACILITY NUMBER: 015600148
VISIT DATE: 10/31/2025
NARRATIVE
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Continued from LIC9099.

Allegation: Staff did not provide adequate supervision resulting in resident wandering away from facility.


Finding: Substantiated

During the interview with S1, S1 stated that they were made aware of the elopement of R1. S1 stated that they were not at the facility when the staff realized that they could not find R1. S1 stated that R1 eloped from the facility on 8/19/2025. S1 stated that they were made aware that R1 was found several blocks from the facility with their walker and had fallen down on the street and a bystander flagged an ambulance which took R1 to the hospital. S1 stated that they received a call from S2 about the situation.

During the interview with S2, S2 stated that they were not at the facility at the time of the situation but was made aware of the situation from a staff member who called them. S2 stated that when they arrived at the facility, the staff at the facility stated that they have been looking for R1 for several hours but could not find R1. S2 stated that R1's responsible party called the facility and let S2 know where R1 was found. S2 stated that the hospital called W1 and let them know how R1 got there. During record review, LPAs observed that R1 is unable to leave the facility unattended. S1 and S2 stated that R1 returned back to the facility the same night. During record review, LPAs observed that R1 was discharged back to the facility the same night and no injuries was noted in the discharge summary.

Allegation: Staff did not inform resident's responsible party of incident.


Finding: Substantiated

During interview with S2, S2 stated that they notified S1 while the situation was happening and received a call from R1's responsible party before the facility could call. S2 stated that while they were looking for R1, they were going to call R1's responsible party after they found R1.

Continued on LIC9099-C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20251027194916
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: ROSEGATE
FACILITY NUMBER: 015600148
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2025
Section Cited
CCR
87468.2(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (4) To care, supervision, and services that meet their individual needs[...] staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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By POC date, the administrator agrees to
1.conduct in-service training in regards monitoring the exit doors and providing adequate supervision for the residents in care
2. replace the auditory device in the main entrance
3. install additional auditory devices in the side gate
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This requirement is not met as evidenced by:
Based on interview and record review, the licensee did not comply with the section cited above by failing to provide sufficient supervision when R1 eloped and was found on the ground 3-4 blocks away and was sent to the hospital which poses an immediate health and safety risk to persons in care.
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LPA will come to verify corrections.
Type B
11/07/2025
Section Cited
CCR
87705(6)(A)
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87705 Care of Persons with Dementia (6) For each incident of elopement, as defined in Section 87101, Definitions, the licensee shall report the incident to:(A) The resident's representative, if applicable, immediately upon becoming aware of the incident. A written report shall also be provided to the resident’s representative [...]
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By POC date, the administrator agrees to conduct in-service training with all staff in regards to notifying responsible parties and send a copy to CCLD by POC date.
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This requirement is not met as evidenced by:
Based on records review and interview, the licensee did not comply with the section above by not notifying R1's RP immediately which poses a potential risk to the health and safety of clients under 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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20251027194916
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ROSEGATE
FACILITY NUMBER: 015600148
VISIT DATE: 10/31/2025
NARRATIVE
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 Continued from LIC9099-C.

A review of R1's Physician's Report dated 4/10/2025 indicates that R1 has Dementia, uses a walker due to unsteady gait and is not able to leave the facility unassisted.

R1 was found by a bystander on East 14 which is approximately 3-4 blocks from the facility. R1 fell and was taken to the hospital with no noted injuries.

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.

Exit interview was conducted with co-administrator and Appeal Rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4