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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600148
Report Date: 08/16/2024
Date Signed: 08/19/2024 08:16:36 AM

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
08/14/2024 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20240814165641
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: 28DATE:
08/16/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Irene De Leon, Facility ManagerTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility does not have a bedridden fire clearance
INVESTIGATION FINDINGS:
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On 08/16/2024 at 9:30AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct complaint investigation for the above allegation and deliver findings. LPA was greeting by Irene De Leon, Facility Manager. Administrator, Jeffrey Tong Administrator arrived at 10:15AM.

LPA collected the following documents for review: All of R1's physicians reports, R1's original appraisal of needs and services, R1's Admissions Agreement. LPA interviewed R1 and observed that R1 is unable to adjust themselves in bed without assistance, and is unable to get up and walk or utilize a wheelchair independently. LPA observed R1 was non-responsive to sound or touch. LPA observed that a Physicians Report dated 8/13/2024 states that R1 is non-ambulatory while the Physicians Report dated 6/13/2024 states that R1 is bedridden. R1 was admitted to the facility on 8/13/2024. The facility is not cleared for Bedridden.

Report Continues on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
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-20240814165641
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: 08/16/2024
NARRATIVE
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LPA spoke with S1 who assists R1. S1 states that R1 is not able to adjust or move by thyself while in bed and needs assistance. LPA also contacted the nurse practitioner that signed the physicians report that lists R1 as non-ambulatory. The nurse practitioner stated that R1 is not able to adjust or move by thyself while in bed. The nurse practitioner stated that they changed R1 from bedridden to non-ambulatory because they observed R1 able to sit up unassisted in a wheelchair. LPA explained that for fire clearance if a person requires assistance with turning or repositioning in bed they are to be deemed bedridden. The nurse practitioner said that they did not know that and that they will update the physicians report back to bedridden.

Facility located a SNF for R1 to go to and has arranged transport for 8/16/2024. R1 is scheduled to move to Marina Garden Nursing Center in Alameda.

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: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240814165641
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: 08/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2024
Section Cited
CCR
87202(a)(2)
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(a) All facilities shall maintain a fire clearance ... Prior to accepting or retaining...(2)Bedridden persons

This requirement is not met as evidence by:
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During visit Administrator arranged for R1 to be transported to a SNF on 8/16/2024.
LPA Assesed a civil Penalty of $500
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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: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3