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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200661
Report Date: 10/14/2021
Date Signed: 10/14/2021 01:55:50 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
09/21/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210921100309
FACILITY NAME:ROSE GARDEN VISTAFACILITY NUMBER:
019200661
ADMINISTRATOR:HASMIN B KOOFACILITY TYPE:
735
ADDRESS:1615 HIGH STREETTELEPHONE:
(510) 533-4929
CITY:OAKLANDSTATE: CAZIP CODE:
94601
CAPACITY:15CENSUS: 14DATE:
10/14/2021
UNANNOUNCEDTIME BEGAN:
01:26 PM
MET WITH:Haidie Bautista, AdministratorTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Resident fell multiple times while in care
INVESTIGATION FINDINGS:
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On 10/14/21 at 01:26 PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit to deliver the findings of above allegations. LPA explained the reason for the visit with administrator.

Allegation: Resident fell multiple times while in care
Investigation Finding: UNSUBSTANTIATED
During investigation, LPAs observed C1 walking around without the aid of the walker. C1 showed LPAs the healed cut on her left knee. C1 stated to LPAs that she has had multiple unwitnessed falls at the facility due to weakness in her left knee. On 09/22/21, she told LPAs she fell and hit her left knee on the metal railing at the front landing close to her bedroom and cut her knee. Staff immediately called 911. C1 was sent to the hospital for evaluation/ treatment, given pain medication and released the same day back with a walker back to the facility. C1 stated she only used the walker once after she came back from the hospital. Based on interviews and record reviews, C1 is ambulatory and does not require assistance with her activities of daily living (ADLs). Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.

No deficiencies cited. Exit Interview conducted and a copy of this report provided
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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-20210921100309
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 GARDEN VISTA
FACILITY NUMBER: 019200661
VISIT DATE: 10/14/2021
NARRATIVE
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Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are unsubstantiated.

No deficiencies cited. Exit Interview conducted and a copy of this report provided

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3