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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200661
Report Date: 08/31/2023
Date Signed: 08/31/2023 02:42:02 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
08/28/2023 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20230828103933
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: 13DATE:
08/31/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Haidie Bautista, Administrator TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Facility is not providing care and supervision to resident.
INVESTIGATION FINDINGS:
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On 8/31/23 at 1:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegations above. LPA met with Haidie Bautista, Administrator and explained the purpose of the visit.

During the course of the investigation LPA interviewed the facility administrator (ADM) and R1 and reviewed R1’s file and obtained R1’s list of medications. R1’s physicians report dated 2/15/23 states R1’s diagnosis as schizoaffective disorder.

R1 was admitted to the facility on 3/09/23 after a yearlong hospitalization at Villa Fairmont. Prior to her stay at Villa Fairmont R1 had numerous psychiatric hospitalizations.

***report continues on LIC9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
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 2
Control Number 15-AS-20230828103933
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: 08/31/2023
NARRATIVE
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***report continues from LIC9099***

ADM stated that R1 has shown some delusional behavior while at the facility. R1 routinely throws her clothes out stating, “I don’t need them, I’m a millionaire.” ADM reported that she has not had any other issues with R1 and is not aware of any un-met care needs..

LPA interviewed R1. R1 was able to state her name and today’s date. R1 could not articulate any un-met care needs that she has had while living at the facility.

LPA also interviewed 3 other residents who all stated that their care needs were being met at the facility.

Based on LPA's interviews and record review we have found that the complaint 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.

Exit interview conducted, a copy of this report provided.


SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2