019200056-5-22-2025-15-AS-YFLS-DHAVKN-20250603163034

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200056
Report Date: 05/22/2025
Date Signed: 05/22/2025 04:04:31 PM

Unsubstantiated

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
03/20/2025 and conducted by Evaluator Luisa Fontanilla

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20250320143652

FACILITY NAME:	ROSE RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	019200056
ADMINISTRATOR:	CARBONEL, JONNASBURG D		FACILITY TYPE:	735
ADDRESS:	4704 ROSE WAY		TELEPHONE:	(510) 441-2258
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	6	CENSUS: 4	DATE:	05/22/2025
		UNANNOUNCED	TIME BEGAN:	02:35 PM
MET WITH:	Jonnasburg Carbonel		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff caused injuries to a client while in care

INVESTIGATION FINDINGS:

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On this day at around 2:35pm, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to deliver finding for the above allegation. LPA met with the Administrator, Jonnasburg Carbonel and explained the purpose of the visit.

On 3/21/2025, LPA L. Fontanilla conducted 10-day visit, obtained records and conducted interviews. On 3/27/2025, LPAs L. Fontanilla and Patricia Manalo conducted additional interviews.

During the course of investigation, LPAs interviewed staff and Client 1 (C1). C1 uses communication device to communicate effectively. C1 can also respond to questions with a nod or shaking of head. C1 denied any mistreatment from staff. Staff interviewed denied hurting or mistreating C1 or any of the clients in the home. A review of C1’s Individual Program Plan (IPP) dated 3/15/2023 indicates that C1 has been living at the facility since 7/1/2003. The IPP indicates C1 likes the home environment, the other residents and the staff.
continuation on Lic 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20250320143652

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: ROSE RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 019200056
	VISIT DATE: 05/22/2025

NARRATIVE

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C1 is non ambulatory and has little control of lower and upper extremities. C1 operates an electric wheelchair using the wheelchair joystick controller with right hand. Sometimes C1 drives too fast, and staff have to remind C1 to slow down.
Due to spasticity, C1 sometimes bumps ankles on the wheelchair tubes connecting to the footrest causing bruises and/sores. When frustrated, C1 sometimes bangs hands and legs on the wheelchair causing minor bruising.

Based on interviews and record reviews conducted, the above allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

There is no deficiency noted.

A copy of this report was provided to the Administrator.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

LIC9099 (FAS) - (06/04)

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